PERIODONTAL CARE PLAN (PCP)

Patient Name: Age: 56

Date of initial exam: September 6, 2019 Date completed: November 19, 2019

1. Medical History: (systemic conditions altering treatment, pre-medication, medical clearance) explain
steps to be taken to minimize or avoid occurrence, effect on periodontal diagnosis and/or care)

Patient is currently under the care of a physician. Patient states that her last physical was August of 2019.
Patient is not under the care of a dentist, has infrequent dental visits, and oral health is not a priority. This
influences the susceptibility or potential risk for the onset or progression of certain oral diseases.
Prescription medications include levothyroxine (thyroid hormone for hypothyroidism), metformin
(treatment of Type 2 diabetes), and metoprolol (beta blocker used for mild to moderate hypertension).
Patient explains that she takes metformin daily, however she did not know her A1c level. People with
diabetes are more likely to have periodontal disease than people without diabetes. This is because people
with diabetes are more susceptible to infections. My patient is considered to have Stage 3 Grade B
periodontal disease. Her periodontal health can actually be a complication of diabetes. Because she does
not have her diabetes under control, she is especially at risk. Periodontitis may make it more difficult for
her to control her blood sugar. This may put her at an increased risk for diabetic complications and further
progression of periodontitis. As the clinician it is key for me to keep appointments short, follow a stress-
reduction protocol, and schedule appointments in the morning. It is important to question whether the
patient has eaten prior to treatment and has taken her medications. Metoprolol can possibly lead to
xerostomia. Reduced salivary flow can cause difficulties in tasting, chewing, swallowing, and speaking; it
can also increase the chance of developing dental decay, demineralization of teeth, tooth sensitivity,
and/or the advancement of her periodontitis. To avoid a severe allergic reaction including anaphylaxis, it
is detrimental to note patient has a Penicillin allergy. Patient does not consume tobacco, alcohol, and does
not have any other systemic conditions.

2. Dental History: (past dental disease, response to treatment, attitudes, dental I.Q., chief complaint,
present oral hygiene habits, effect on periodontal diagnosis and/or care)

Patient reported she has not had a dental cleaning in years and is not under the care of a dentist. In past
dental checkups, pt. noted on medical/dental hx she has many cavities. Because she is a diabetic, I can
assume that the pt.’s oral health has intensified over time since her last dental visit. Patient’s infrequent
dental exams increases the potential risk for the progression of her periodontal disease. Patient feels the
appearance of her teeth/smile are “Ok”. Type and date of most recent dental x-rays were an FMX in April
2019 at LIT Dental Hygiene Clinic. Prior to her screening at LIT, the last dental x-rays taken were in
2008. September 6, 2019, I took vertical BWX to check pt.’s bone level. After evaluation of pt.’s x-rays,
patient’s periodontal condition is Stage 3 Grade B, meaning pt. has moderate to severe periodontitis and is
expected to progress at a moderate rate based on systemic health. According to the American Academy of
Periodontology, “Staging intends to classify the severity and extent of a patient’s disease based on the
measurable amount of destroyed and/or damaged tissue as a result of periodontitis. Grading aims to
indicate the rate of periodontitis progression, responsiveness to standard therapy, and potential impact on
systemic health.” Pt.’s teeth do not feel sensitive to hot, cold, sweets, or pressure; nor does she note signs
of mouth breathing or tongue thrust. Periodontal risk factors include poor plaque control, radiographic
loss of crestal bone, clinical recession, diabetes, chronic BOP, and prior caries experience. Patient also
ranks high for restorative risk factors including poor/faulty restorations, missing teeth (#3), malocclusion
(Class III), and decreased salivary flow. Patient recalls that she is often thirsty. Xerostomia can also
increase the chance of developing dental decay, demineralization of teeth, tooth sensitivity, and/or
increase pt.’s progression of periodontitis. The intraoral pictures taken were disconcerting to the patient.
Having a visual appearance of her teeth, especially the calculus buildup in the mandibular anterior
linguals, expressed the severity of her present appearance. She was then interested in learning how to stop
the progression of her periodontitis and displayed interest in making her oral heath a priority.

3. Oral Examination: (lesions noted, facial form, habits and awareness, consultation, effect on
periodontal diagnosis and/or care)

Extraoral: Patient reveals no physical limitations. In 2004 patient was diagnosed with hypothyroidism and
is currently prescribed levothyroxine used to treat her underactive thyroid. This prescription medication
could impair oral hygiene by causing a decrease in salivary flow and an increase in bacterial growth,
making the patient at a higher risk for caries and advancement of her periodontal disease. No other signs
of atypical or pathological findings contribute to her periodontitis

Intraoral: Findings include bilateral linea alba found on the buccal mucosa, reduced salivary flow
(xerostomia), and bilateral slight mandibular tori located on the floor of the mouth. As previously stated
without the natural defense of saliva, plaque and bacteria can build up quickly at the base of your teeth,
making you more susceptible to bad breath, tooth decay and gum disease. Patient also loses saliva's
ability to help repair and remineralize weak tooth enamel. Patient has an occlusion of three on the right
canine, however the classification based on the right molar could not be detected due to pt. missing tooth
#3. Occlusion on the left could be classified as class three based on the left molar and left canine. Other
findings for occlusal examination include 3mm overbite, 4mm overjet, open-bite #’s 6, 7, and 10, and
4mm mid-line shift to the left. Oral habits displayed are grinding and clenching at night as stated by the
patient. If frequent and severe enough, bruxism can lead to jaw disorders, headaches, damaged teeth and
other problems. Patients poor oral habits have already impacted her oral health. Clinical signs of
generalized recession can be found on the maxillary and mandibular posterior teeth. Patients malocclusion
can have restorative risk factors which includes caries, trauma, and structural breakdown. Patient has no
other findings that would contribute to her periodontitis.

4. Periodontal Examination: (color, contour, texture, consistency, etc., effect on periodontal diagnosis
and/or care)

a. Periodontitis Stage: III Periodontitis Grade: B Extent & Distribution: Generalized moderate to
severe periodontitis with potential for additional tooth loss with a moderate rate of progression

Describe determining factors/ etiology behind Stage, Grade. & Extent of disease findings:
Staging intends to classify the severity and extent of the patient’s disease based on the measurable amount
of damaged tissue as a result of periodontitis. My patient showed radiographic bone loss extending to the
middle third of the root and beyond, presented with tooth loss, and probing depths as high as 6mm. This
puts her in stage III of periodontitis. Grading aims to indicate the rate of periodontitis progression,
responsiveness to standard therapy, and potential impact on systemic health. Pt.’s direct evidence of
progression of radiographic bone loss is <2mm over 5 years. Destruction is equal with biofilm deposits
and the rate of disease progression is directly impacted by patient’s uncontrolled diabetes. This grades her
at a moderate rate, Grade B.

b. Gingival Description: Generalized moderate to severe periodontitis with moderate bleeding

App’t 1: Baseline
Architecture: Generalized scalloped
Color: Localized redness on mandibular anterior facial and lingual #’s 22-27 and mandibular
posterior lingual #’s 1, 2, 3, 5, 12, 13, 15, 16.
Constancy: Localized edematous/spongy mandibular anterior #22-27L
Margins: Generalized rolled margins mandibular posterior lingual and mandibular anterior lingual.
Papillae: Localized bulbous #22-27F and generalized blunted maxillary and mandibular posterior
facial and lingual.
Suppuration: None
Surface Texture: (Papillary and marginal) Generalized smooth and shiny
Surface Texture: (Attached) Generalized smooth and shiny with stippled features on the maxillary
anterior facial and lingual.

Red, edematous, rolled, bulbous, and blunted gingiva are indications of disease. We will need to
evaluate the removal of bacteria/calculus in order to halt the progression of her periodontitis.

App't 2: Gingiva of Entire Mouth

Architecture: Generalized scalloped
Color: Localized redness on mandibular anterior facial and lingual #’s 22-27 and mandibular
posterior lingual #’s 1, 2, 3, 5, 12, 13, 15, 16.
Consistency: Localized edematous/spongy mandibular anterior #22-27F/L. Localized
edematous/spongy maxillary and mandibular molars #’s 1, 2, 14, 15, 16, 17, 18, 19, 30, 31, and 32.
Margins: Generalized rolled margins mandibular posterior lingual and mandibular anterior lingual.
Papillae: Localized bulbous #22-27F and generalized blunted maxillary and mandibular posterior
facial and lingual.
Suppuration: None
Surface Texture: (Papillary and marginal) Generalized smooth and shiny
Surface Texture: (Attached) Generalized smooth and shiny with stippled features on the maxillary
anterior facial and lingual.

Red, edematous, rolled, bulbous, and blunted gingiva are indications of disease. We will need to
evaluate the removal of bacteria/calculus in order to halt the progression of her periodontitis.

App't 3: Gingiva of the Maxillary Right

Architecture: generalized scalloped
Color: Generalized pink with localized redness on #1 and #2B and #8L
Consistency: Localized edematous/spongy on #8L
Margins: Rolled on #8L
Papillae: Bulbous on #8L
Suppuration: None
Surface Texture (papillary and marginal): Generalized smooth and shiny
Surface Texture (attached): Generalized stippled

After completing ultrasonic to clean the maxillary right quadrant, I have noticed an immense
difference in her gingival appearance. Tooth #8 on the lingual aspect still showed some inflammation
along with #1 and #2B in the posterior area. The red, rolled, bulbous and shiny appearance indicates
that there still may be trace amounts of bacteria. This indicates disease. Once removed by fine
scaling, we can get those few areas back to health and halt her periodontal disease.

App't 4: Gingiva of Mandibular Left

Architecture: generalized scalloped
Color: Generalized pink with localized redness on #19L and #23L, #24L
Consistency: Normal
Margins: Normal
Papillae: Bulbous on lingual anterior
Suppuration: None
Surface Texture (papillary and marginal): Generalized smooth, shiny on #19 lingual
Surface Texture (attached): Generalized stippled

After using the ultrasonic and fine scaling this quadrant, I noticed a difference in her gingiva. The
only redness I recorded was on #19L and the linguals of her anterior teeth (primarily #’s 23 and 24).
Also, her lower anterior’s were still a little bulbous. At this stage of treatment, I should assess her oral
home care routine and make sure she is getting to those areas to help stop the progression of her
periodontitis.

App’t 5: Gingiva of Mandibular Right

Architecture: Localized Flat on mandibular posterior #’s 32, 31, and 30.
Color: Generalized pink
Consistency: Normal
Margins: Normal
Papillae: Bulbous on lingual of anterior
Suppuration: None
Surface Texture (papillary and marginal): Generalized smooth
Surface Texture (attached): Generalized stippled

After completion of the mandibular right, I was amazed. The only area of concern was the bulbous
papillae of the anterior lingual. It has been a few weeks since her last appointment, therefore it is
apparent she builds bacteria in that area more quickly causing the enlargement. I made sure to
reiterate the removal of the bacterium by reviewing the brushing and flossing skills taught in the
patient education room. Proper technique will ensure to slow the rate of progression of her disease.

App't 6: Gingiva of Maxillary Left

Architecture: Flat papillae on #12-#13 facial.
Color: Generalized pink
Consistency: Normal
Margins: Normal
Papillae: Normal
Suppuration: None
Surface Texture (papillary and marginal): Generalized smooth
Surface Texture (attached): Generalized stippled

These clinical findings show that the patient responded well to scaling and root planning of the
maxillary left. There was no redness, bulbous, or edematous areas that would identify disease. These
results indicate that the patient is on the right track to stopping the progression of her periodontitis.

c. Plaque Index: Appt. 1: 1.83 (Fair)

Appt. 2: 1.4 (Good)
Appt. 3: .83 (Good)
Appt. 4: .8 (Good)
Appt. 5: .6 (Good)
Appt. 6: .8 (Good)

d. Gingival Index: Initial: 1.45 Final: .6

e. Bleeding Index: Appt. 1: 17.7% (Baseline)

 Appt. 2: 10%
Appt. 3: 10%
Appt. 4: 6.66%
Appt. 5: 6.66%
Appt. 6: 0%

f. Evaluation of Indices and effect on periodontal diagnosis and/or care:

1.Initial: These indices are all contributing factors to pt.’s periodontal disease. This patient is a
Stage III Grade B, which means severe periodontitis with potential for additional tooth loss with a
moderate rate of progression is present. She has a plaque score of 1.83 (fair). This shows patient
has poor plaque control. Proper brushing technique and flossing need to be assessed to effectively
remove bacteria on the surfaces of teeth. If plaque is not removed, her disease could progress. Her
gingival index reveals that her gingiva has a fair score of 1.45. Bleeding index has a baseline of
17.7%. Both gingival index and bleeding score indicate inflammation and disease. If scores are
not lowered, disease progression will persist. Patient uses a medium bristle toothbrush and uses
the scrub brush method. This can lead to toothbrush abrasion causing sensitive teeth and receding
gums. Patient brushes morning and night with Crest whitening toothpaste and rinses with Scope
nightly. However, pt. states she does not floss. This can result in bacteria build up between teeth
causing decay and bleeding gums. Other common problems that occur with limited flossing and
unhealthy oral practices include plaque buildup, that can harden and become calculus. This all
greatly impacts the rate of progression of patient’s current disease state.

2. Final: Now that the patient has learned the proper technique of brushing and flossing and had a
professional cleaning treatment to her teeth, one can acknowledge the improvement in these
indices. She has lowered all scores including plaque score, bleeding score, and gingival index.
This shows that my patient is on her way to recovery and is willing to stop the progression of her
disease by using proper technique and a continuous home care routine.

g. Periodontal Chart: (Record Baseline and First Re-evaluation data, effect on periodontal diagnosis
and/or care)
1.Baseline: Active disease is considered when periodontal pockets measure 4mm and above.
Pockets of this kind make it difficult for the patient to access these areas resulting in periodontal
progression. I recorded 4, 5, and 6 mm pockets mainly in the posterior regions. It was sometimes
difficult to get an accurate reading because of the subgingival calculus buildup. While probing,
there was no suppuration. The patient also has recession in the posterior of both arches. Recession
cannot be reversed, but it can be halted just like periodontitis. After I ultrasonic each quadrant, I
will then be able to get a more accurate pocket depth, recession measurement, and determine the
clinical attachment loss. The patient has occlusal restoration on #14 and Occlusal/Buccal
restoration on #’s 19 and 30. Suspicious areas are noted on the occlusal of #’s 2, 17, 18, 31, and
32 with recurrent decay on #’s 14 and 30. Diastema can be seen between tooth #’s 6 and 7; 8 and
9; 9 and 10. A diastema that occurs because of a mismatch between the teeth and the jaw does not
have symptoms. However, spaces caused by periodontal disease will tend to expand or grow with
time. The teeth may become loose, and discomfort or pain may occur. Patient is missing tooth #3.
This is often caused by poor nutrition, oral habits, and disease, ultimately affecting the rate of
periodontal progression. Radiographically, generalized moderate horizontal bone loss is present
in both arches anterior and posterior. Generalized loss of crestal bone is seen on maxillary and
mandibular; anterior and posterior. Calculus can be seen on the radiographs in UR, UL, LA, and
LR. It is clear that the patient’s bone receded due to the inflammatory response to bacteria.
Though the patient’s disease is graded at a moderate rate of progression, learned oral hygiene
habits can slow the progression. Periodontitis cannot be reversed, but it can be halted.
 2. First evaluation: Now that my patient is knowledgeable in her oral health her host immune
response is responding well after the removal of bacteria. Healing is evident and many
improvements have been noted in each quadrant. In all four sections of her posterior teeth, her
pocket depths have lowered by 1 or 2 mm. Most of the pocket depths in the anterior region either
lowered by 1mm or remained the same. I do believe though the areas that showed no change will
lower with time and stop the progression of her disease. You can also see lowering in the loss of
attachment as well. There was no suppuration when probing. The patient is missing tooth #3 from
after extraction do to decay. The patient has occlusal restorations on #14, 19, and 30. There are
buccal restorations on #19 and #31. There are suspicious areas on the occlusal of #2, 17, 18, 31, and
32. Recurrent decay is visible on #14 and #30. It was advised that the patient had these areas
looked at by her family dentist to prevent the progression of her caries and disease. Diastema can be
seen between tooth #’s 6 and 7; 8 and 9; 9 and 10. A diastema that occurs because of a mismatch
between the teeth and the jaw does not have symptoms. However, spaces caused by periodontal
disease will tend to expand or grow with time. The teeth may become loose, and discomfort or pain
may occur. She is aware that proper brushing and flossing can halt the disease. Radiographically,
generalized moderate horizontal bone loss is present in both arches anterior and posterior.
Generalized loss of crestal bone is seen on maxillary and mandibular; anterior and posterior.
Calculus can be seen on the radiographs in UR, UL, LA, and LR. It is clear that the patient’s bone
receded due to the inflammatory response to bacteria. Though the patient’s disease is graded at a
moderate rate of progression, learned oral hygiene habits can slow the progression. The patient is
now aware that periodontitis cannot be reversed, but it can be halted. She wants to make a change
to her oral health.

5. Dental Examination: (caries, attrition, midline position, mal-relation of groups of teeth, occlusion,
abfractions, effect on periodontal diagnosis and/or care)
SA: #30OB with recurrent decay
W: #2O, 14O (recurrent decay), 17O, 18O, 31O, 32O
Midline: 4mm to left
Occlusion: Pt. missing #3; molar classification on the right could not be determined. Right canine: Class 3
Left molar and canine Class 3.
Overbite: 3mm
Overjet: 4mm
Missing Teeth: #3
Tooth Colored Restoration TCR: #14 (W recurrent decay), 19, and 30OB (recurrent decay)
Decalcification: #4F, 5F, 11F, 12F, 13F

The suspicious areas are of concern. If left untreated, this will lead to further progression of periodontitis.
Decay process that occur underneath existing restorations can compromise the structure of the tooth all
over again. This will also impact pt. current state of disease. Patient’s malocclusion and misalignment in
the anterior portions of the mouth can make it hard for the patient to affectively remove plaque and food
debris contributing to the progression of disease. Lastly, in Class III, the lower jaw actually protrudes,
causing an underbite where the lower teeth close in front of the upper teeth. Left untreated, it can lead to
tooth damage and difficulties with speaking and chewing. Additionally, this improper bite can cause
problems in the temporomandibular joint (TMJ), causing pain and difficulty chewing.

6. Treatment Plan: (Include assessment of patient needs and education plan)

App't 1:
 Medical/Dental history
  Vitals
 Statement of Release
 HIPAA
 Patient Appointment Practice
 Pre-Rinse
 Vertical BWX (check bone level)
 Intra and Extraoral exam
 Dental Charting with x-rays
 Periodontal Assessment
 Bleeding Score
 Plaque Score
 Risk Assessment
 Informed Consent: referral for caries on #30 OB
 Gingival Index
 Intra Oral Pictures
 Learning Level: Unaware. Patient is in need of proper teaching so she can halt the progression of
her periodontal disease. Patient is willing to learn.

App’t 2:
 Medical/Dental history
 Vitals
 Pre-Rinse
 Bleeding and Plaque score: compare from last appt.
 Assess gingival condition
 Ultrasonic max right
 Full perio charting on max right
 Fine scale max right

 Patient Ed Session 1: Plaque and Brushing

o I will discuss all long-term goals listed for all patient education sessions. I will then discuss
the short-term goals from this session. We will then agree upon goals and make
adjustments if needed during treatment for the patient.
o LTG 1: Patient will reduce bacteria count in the mouth by lowering her score from fair to
good by the last appointment which is between 0.1-1.7.
 STG: Patient will be able to define plaque and use disclosing solution to
determine where plaque buildup is by the 2nd visit.
 STG: Patient will learn bass method and how this technique to reduce tooth
abrasion and lower bacteria count. She will be able to demonstrate by the 2nd
visit.
 STG: Patient will decrease her plaque score at each visit by 1 point
o Define plaque by using flipbook. Discuss the plaque score and teach patient how to reduce
this score by next visit. Discuss why plaque is harmful. Teach bass method and have patient
demonstrate what they have learned. Make adjustments if needed. Review and discuss next
appointment. Assure patient that we are a team!
App’t 3:
 Medical/Dental History
 Vitals
 Pre-Rinse
  Plaque Score
 Bleeding Score
 Assess gingival condition
 Ultrasonic max left
 Full perio charting on max left
 Fine scale max left

 Patient Ed Session 2: Periodontitis and Flossing

o Review learning topics from first session. Restate long terms goals for all patient education
sessions. State long and short-term goals from this session. We will then agree upon goals
and make adjustments if needed during treatment for the patient.
o LTG 2: Patient will achieve to stop the progression of his periodontal disease by lowering
her bleeding score to 5% by his last appointment
 STG: Patient will be able to identify periodontitis and understand that it is
irreversible by the next appointment.
 STG: Patient will demonstrate proper flossing technique learned in patient
education and understand why flossing is important to halt the progression of
bone loss by next appointment.
 STG: Patient will decrease bleeding point score by 3% by 3rdnd visit and set up
recall appointment in the next 3-4 months.
o Have patient start by defining plaque and bass method brushing technique learned from
last session. Reassure that pt. fully understands the method and have them demonstrate
technique again. Make changes if needed. Define and explain periodontitis while using
patient’s recent vertical BWX x-rays and FMX from spring 2019. Emphasize the
significance of bleeding points related to active disease. Have patient understand the
progression of periodontitis is irreversible, but she can halt the progression with proper
oral hygiene habits at home. Teach flossing technique. Have patient demonstrate
technique in mirror. Discuss what goals were met. Review and discuss next appointment.

App’t 4:
 Medical/Dental History
 Vitals
 Pre-Rinse
 Plaque Score
 Bleeding Score
 Assess Gingival Condition
 Ultrasonic mandibular right
 Full perio charting mandibular right
 Fine scale mandibular right

 Patient Ed. Session 3: Caries

o I will review long and short-term goals from this session. We will then agree upon goals
and make adjustments if needed during treatment for the patient.
o LTG 3: Patient will understand the caries process and how her systemic condition
(Diabetes) relates to the caries process by next recall appointment.
 STG: Patient will understand that her systemic involvement puts her at a higher
risk for caries by the next appointment.
  STG: Patient will be able to define xerostomia and understand the use of her
medications contributes to reduced salivary flow. By next appointment she will
understand how this is a factor in the caries process.
 STG: Patient will start using xylitol products and fluoride daily rinses not
containing alcohol to alleviate symptoms of dry mouth and ultimately stopping
the development of caries by next appointment.
o Review plaque, brushing, flossing, and periodontitis. Have patient brush and floss with
correct technique learned from past 2 visits. Make adjustments as needed. Use flipbook to
teach importance of her caries risk with the contribution of xerostomia (caused from
medications) in connection with pt.’s uncontrolled diabetes. Review risk assessment.
Introduce dry mouth products and encourage using xylitol products to increase salivary
flow. Discourage use of alcohol containing products. Have patient know her recall time is
3-4 months to observe her progress. Check that goals were attained and review all
lessons. Schedule 3-4 month recall visit.
App’t 5:
 Medical/Dental History
 Vitals
 Pre-Rinse
 Assess gingival condition
 Plaque Score
 Bleeding Score
 Ultrasonic mandibular left
 Full perio charting mandibular left
 Fine scale mandibular left
 Make 2-week appointment

App’t 6:
 Medical/Dental History
 Vitals
 Pre-Rinse
 Assess gingival condition
 Final gingival Index
 Plaque Score
 Bleeding Score
 Plaque Free
 Fluoride
 Arestin
 Make 3-month recall
 Ask patient if they have any other questions about treatment
 Assess goals with patient again and review education topics

7. Radiographic Findings: (crown root ratio, root form, condition of interproximal bony crests,
thickened lamina dura, calculus, and root resorption; effect on periodontal diagnosis and/or care)
 Generalized moderate horizontal bone loss
 Loss of crestal lamina dura
 Calculus: Lower anterior #22-27
 Defective restorations: #14 and #30
 Missing Teeth: #3
The radiographic findings show the patient has generalized moderate horizontal bone loss. The patient
also displays with the loss of crestal lamina dura. The calculus seen on teeth #22-27 will be more
susceptible to additional bone loss if not removed. The plaque has spread to the bone and begins its bone-
destroying process. Because the patient has infrequent dental exams, the bacteria will become more
aggressive, which will cause the additional bone loss. This will affect the rate of progression of her
periodontitis.

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.

1st appt.: Patient is not under the care of a dentist, has infrequent dental visits, and oral health is not a
priority. This influences the susceptibility or potential risk for the onset or progression of certain oral
diseases. I took vertical BWX to determine what kind of state my patient’s bone level was in. I
explained to her that these radiographs would show us a better understanding of where her bone
levels were.

2nd appt.: At this appointment, I started with head and neck exam, dental charting, risk assessment,
and informed consent. After completion of this paperwork, we determined that she had moderate to
severe horizontal bone loss in both arches anterior and posterior. This patient is a Stage III Grade B,
which means severe periodontitis with potential for additional tooth loss with a moderate rate of
progression is present. The referrals made by the dentist included #30 recurrent decay. It was advised
that she see this family dentist to have this looked at. A plaque score was taken at 1.83, which is fair,
and her bleeding score was at 17.7%. I had the patient look in the mirror to show her where she is
missing when she brushes. I then explained to her the areas that bled to show that there is
inflammation indicating active disease. I took a few intraoral pictures including the mandibular
anterior lingual, rolled lingual margins in the posterior and visible recession on tooth #’s 12-14.
Patient felt that the appearance of her smile was just “ok”.

3rd appt.: Plaque score and bleeding were taken again. She lowered it to 1.4 and lowered her bleeding
score to 10%. We then started patient education and talked about plaque and brushing. We reviewed
her long-term goals and short-term goals and made sure they were goals she could attain. I defined
plaque as being a sticky, yellow bacteria that forms on the teeth. It can be caused by sugary or starchy
foods. If not removed, caries could form that could progress periodontitis. I showed her the intraoral
pictures to display the plaque. Next we talked about the removal of plaque by brushing. I
demonstrated the bass method by holding the brush at a 45-degree angle while using a soft grasp. I
explained the benefits of soft bristle toothbrush and proceeded with an overlapping vibrating motion.
Brushing twice a day for 2 minutes is recommended. I used disclosing solution and had patient
demonstrate for me. We reviewed the skills taught that day and the patient was enlightened by the
new information she learned. Before our patient education session, Mrs. Olguin was unaware of how
to properly brush her teeth. We then went back to the chair and used the ultrasonic on the maxillary
right in order to remove the calculus and stop the progression of periodontitis. Accurate pocket
depth, tissue height, and clinical attachment loss were then calculated. I ended the appointment by
fine scaling the maxillary right to eliminate any bacteria/calculus that was not removed by the
ultrasonic.

4th appt.: Plaque was lowered to 0.83, which met her short-term goal. Bleeding score remained at
10%. This patient education session was about periodontitis and flossing. Before we began our new
topic and skill, we reviewed brushing and plaque form our previous session. I had the patient
demonstrate the bass method on the typodont model once more. I highlighted that she met all short-
term goals. Next, we went over her long term and short-term goals for this session. I explained that
periodontitis is loss of bone and ligament that cannot be reversed, but it can be stopped. I used the
patients radiographs and bleeding points to give her a better understanding of what periodontal
disease is. I also told her it is recommended for all periodontal involved patients should have a
professional cleaning and exam every 3-4 months to monitor the loss of bone. I then taught her how
to floss with a C shape motion, wrapping around the tooth, to go beneath the gumline, and apply light
pressure. I then explained to floss once a day to remove the bacteria between the contacts of the teeth
and had the patient demonstrate for me with disclosing solution. Patient was then able to review this
session. Since her plaque score was lowered, it was evident that some involvement was taking place
at home. Patient was amazed by the amount of knowledge she did not know. I then brought her back
to the chair and proceeded with the ultrasonic on the mandibular left. Probe depths, tissue height, and
clinical attachment loss were calculated. Then I fine scaled this area to remove all calculus and stop
the progression of periodontitis.

5th appt.: Plaque score was at 0.8 and bleeding remained at 10%. For the 3rd session of patient
education, patient will understand the caries process and how her systemic condition (Diabetes)
relates to the caries process. First, we went over the goals from last session and congratulated the
patient on meeting her short-term goals. She was proud of what she had accomplished. She even
mentioned that when she brushes, she remembers the correct technique and makes sure to get the
linguals of her mandibular anterior teeth. I then went over today’s session of short- and long-term
goals. I talked about the caries process and how they form. When then discussed how to prevent
them. I showed the patient her risk assessment to give her a visual that she is currently at a high risk
for developing caries. Lastly, we touched on how the patient’s systemic disease plays a vital role in
her host immune response to bacteria. She now understands that diabetics have a comprised immune
system and that excellent oral hygiene is key to health. Xerostomia was also defined. To help
alleviate symptoms, Biotene (sample given) and other over the counter products were discussed. I
then proceeded to explain that dry mouth could also cause caries as well. I advised patient to avoid
alcohol-based mouth rinses and use fluoride-containing products to remineralize her teeth. Patient
was very responsive in all patient education topics and received a learning level of action. She could
not thank me enough for all the information given. We then went back to the chair and I used the
ultrasonic on the mandibular right. Probe depths, tissue height, and clinical attachment were
calculated. I then fine scaled to remove all calculus to carry on track to health.

6th appt.: Plaque score lowered to .6 and her bleeding score lowered to 6.66%. At chair side I asked if
she had any questions over the topics or skills learned. I also asked her how her home care was going.
Patient still showed a learning level of action. At this appointment, I completed treatment. I used the
ultrasonic on the maxillary left. Then I calculated the pocket depths, tissue height and clinical
attachment loss. Finally, I scaled the area to remove any bacteria/calculus that was not removed by
the ultrasonic. This disruption of bacterium will lead to stopping the progression of her disease. I
ended with plaque free, applied a sealant to tooth #28, and applied fluoride varnish. I instructed
patient to not brush until nighttime, and to not eat hard, sticky, or hot substances for the next 4-6
hours to keep the fluoride activated as long as possible.

7th appt.: This appointment was her 2-week post-perio/post-cal re-evaluation. I checked for any
residual calculus and removed what was felt. I then completed a full periodontal charting with pocket
depths, tissue heights, and clinical attachment loss to compare from the initial appointments to record
any improvements in health. A final gingival index was taken, and it lowered to a 0.6 (Good). Her
plaque score was at a 0.8 and her bleeding score reached 0% (Excellent). We went over all topics
again and she is making it a habit in her oral care. Arestin was then inserted in 8 areas of her mouth
with pocket depths of 5mm or greater. I explained to her that this antimicrobial antibiotic will fight
 the bacteria deep in the pockets that I couldn’t get to and further stop the progression of her disease. I
instructed her to keep those areas undisturbed by not flossing those teeth for the next 10 days.

9. Prognosis: (Based on attitude, age, number of teeth, systemic background, malocclusion, tooth
morphology, periodontal examination, recare availability)

My patient is 56 years of age. Prescription medications include levothyroxine (thyroid hormone for
hypothyroidism), metformin (treatment of Type 2 diabetes), and metoprolol (beta blocker used for mild to
moderate hypertension). Patient explains that she takes metformin daily, however she did not know her
A1c level. People with diabetes are more likely to have periodontal disease than people without diabetes.
This is because people with diabetes are more susceptible to infections. I always made sure to ask my
patient prior to her appointment if she has taken her medication and if she has eaten. Other than these few
systemic conditions, she is a healthy individual whose knowledge of oral hygiene is unknowing. With
routine cleaning, oral care, and patient education she has a good prognosis of halting the progression of
her disease. This is something she will have to make part of her everyday routine.

10. Supportive Therapy: Suggestions to patient regarding re-evaluation, referral, and recall schedule.
(Note: Include date of recall appointment below.)

During re-evaluation, I suggested a couple of things. I told her to make sure to see a dentist to restore her
recurrent decay on tooth #30. This area needs to be treated in order to save adjacent teeth and stop the
contribution to her disease. I suggested as well the recall date. Since a periodontal involved patient needs
to see the dentist office every 3-4 months, I set her date to February of 2020. This way we can stay on top
of her current disease state of periodontitis to make sure it is halted and maintained. I reiterated the proper
brushing and flossing at this re-evaluation as well because home care is key to maintaining health.

11. Assessment of Changes: (note “Grade” at the end of treatment, compare changes in periodontitis
classification, changes in plaque control, bleeding tendency, gingival health, probing depths, effect
on periodontal diagnosis and/or care)

From the first appointment to the last appointment, there has been some significant changes. Her plaque
control starting at a 1.83 (Fair) and brought down to a 0.8 (Good). Patients bleeding score starting at
17.7% and reduced to 0%. This proved that proper patient education and practiced skills of brushing and
flossing can lower the bacteria count and essentially halt periodontitis. My patient even noticed a decrease
in bleeding with brushing and flossing at home. Once each quadrant was cleaned, you could see a
noticeable difference in the gingival health status. The gingival index from the first appointment started at
1.45 and lowered to a 0.6. Along with the plaque score, bleeding score, soft tissue examination of the
periodontal assessment, even the probing depths were reduced as well and showed that the progression of
her periodontal disease is controlled. My patient showed radiographic bone loss extending to the middle
third of the root and beyond, presented with tooth loss, and probing depths as high as 6mm at the initial
appointment. This put her at stage III of periodontitis. Grading aims to indicate the rate of periodontitis
progression, responsiveness to standard therapy, and potential impact on systemic health. Pt.’s direct
evidence of progression of radiographic bone loss is <2mm over 5 years. Destruction is equal with
biofilm deposits and the rate of disease progression is directly impacted by patient’s uncontrolled
diabetes. This grades her at a moderate rate, Grade B. If my patient continues to practice good oral
hygiene habits, attends her 3-4month recall visits for professional cleanings, and works to get her diabetes
well controlled, I believe she will significantly lower her rate of progression of periodontitis.
12. Patient Attitudes and Cooperation:

From the very first phone call I could tell my patient was eager to make a change in her oral health. I
believe she did as best as she knew how at home but lacked the educational knowledge to make her
current hygiene routine effective. She was unaware that proper brushing/flossing technique, systemic
involvement, medications, and nutritional habits played a huge role in her periodontitis. When intraoral
pictures were taken, she was appalled by the appearance. After our three patient education sessions, she
was extremely surprised on how uneducated she was about the importance and current status of her oral
health. She knew her mouth was in poor condition, but she did not realize how much of an affect it had on
her overall health. My patient was very responsive in our sessions and it showed in her indices. She has
made great efforts in changing her home care routine and agrees to maintain it. Visual changes from her
smile to how her teeth feel was the best way for her to realize it was time to make a much needed change
to stop the progression of her disease.

13. Personal Evaluation/Reaction to Experience:

This has been the most rewarding process my entire semester. I felt honored to help another person
understand her oral health as a priority, and it personally made an impact on me as a hygiene student
knowing I played a role in educating, motivating, and successfully treating a patient with periodontitis. I
even surprised myself of my own knowledge that I have carried with me throughout this journey. I feel I
am confident enough to present information to my patients and give them the best oral care treatment and
advice. Periodontitis is an urgent topic that easily goes unidentified if a patient shows no symptoms or is
uneducated about the topic. With my knowledge and skills, I know I can teach my patients to reverse or
halt their progression of periodontal disease.