Treatment Planning

Caitlin Berge I. Assessment A. Patient interview The patient stated there were no changes in medical history or medications. She stated she was in for a routine cleaning and dental exam—she is consistent with 6-month recall appointments. The patient stated she was experienced mild pain on tooth #30. The patient said she uses a manual toothbrush and flosses 2-3 times per week, and reports having difficulties flossing certain areas where the contacts are too tight. B. Medical / dental history The patient is 73 years old and has schizophrenia and type II diabetes and both are currently controlled with medication. Additionally, she is completely deaf in her left ear and had a total knee joint replacement in 2012. She currently has no allergies but has a sensitivity to mint flavored toothpastes and polishes. She takes Humulin, Glimepiride, and Metformin for treatment of type II diabetes. Metformin can cause taste disorder, and for all three the patient should be asked about her last meal, medications taken, and have her appointment scheduled in the morning to reduce the risk of stress induced hypoglycemia. She is taking Venlafaxine for depression and generalized anxiety disorder—effects include xerostomia and possible increased bleeding. She is taking Risperidone for the treatment of schizophrenia. Dental effects include xerostomia and possible toothache. The patient is taking Detrol for the treatment of an overactive

bladder, which can cause xerostomia. Additionally, she is prescribed Triamcinolone Acetonide Cream for dermatoses and oral inflammatory/ulcerative lesions, which can cause ulcerative esophagitis, perioral dermatitis, atrophy of oral mucosa, burning, and irritation. She is also taking Triamterene for the treatment of edema as well as Florajen 3 probiotic and a multivitamin, none of which have any effects or interactions. C. Social History Patient is a nonsmoker and drinks 2 or fewer drinks per week. D. Vital Signs Blood pressure 143/87. Patient is 5’7” and weighs 260 lbs. E. Intra-oral / extra-oral examination Intra-oral examination findings include a plaque score of 16%. Cheek bite present on left buccal mucosa. Fordyce granules present on the lips and buccal mucosa. Incisive papilla present, as well as varicosities on the ventral surfaces of the tongue. Gingiva is generalized pink with localized redness on the buccal and lingual of the lower anteriors, Interdental papilla is generalized pointed/normal. Gingiva is generalized stippled and firm and resilient. Localized recession is present on the buccal surfaces of all canines. Class II occlusion right and left, 5 mm overjet, moderate overbite. Patient has severe xerostomia. Extra-oral examination findings include a slight click in the left TMJ (asymptomatic), and extremely dry/chapped lips. All other assessments reported within normal limits. F. Periodontal examination

Generalized 1-3mm probing depths, localized posterior 4 mm probing depths with 5mm on #30 ML. There was generalized spontaneous bleeding on probing. No furcations present.

G. Radiographs Periapical of #30 made. Generalized horizontal bone loss evident in past CMS.

II. DH Diagnosis (Problem identification) A. Level of health Patient is in fair physical health. Her BMI is high, but her diabetes is managed with medications. Patient’s oral health status is fair. B. Diagnosis The periodontal case type is generalized slight chronic periodontitis.

III. Plan A. Consultations Necessary Patient needs to see the dentist for a regular check-up and comprehensive exam. Specifically assess teeth #30 for pain and discomfort. Dentist will need to implement planned treatment if necessary. B. Treatment goals Reduce bleeding and reduce amount of calculus. Decrease inflammation and control probing depths as well as manage severe dry mouth.

C. Addresses phases of treatment §

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

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Phase II surgical – none

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Phase III restorative – possible action required for #30 determined by dentist’s comprehensive exam

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Phase IV – 6-month recall for dental prophylaxis

IV. Implementation Appointment: Hand scale 4 quadrants, have comprehensive dental exam. Kept a small cup of water on dental unit to wet mirror so it would not stick to patient’s cheek. Exam showed no new findings and existing restorations were intact. Patient was instructed to return if pain on #30 intensifies. Showed patient bass brushing method and c-wrap flossing. Showed proper use of soft picks in order to floss tight contacts. Instructed patient how to use biotene mouth rinse to reduce dry mouth. Alterations include asking the patient when she last ate and if she took her medication, as well as her last blood sugar reading. Patient was scheduled in the morning to help prevent stress-induced hypoglycemia. The patient was monitored throughout the appointment to see if sweat was accumulating on the face especially the upper lip (indication of hypoglycemia). Her diabetes can exacerbate her periodontitis and vice versa, and the severe xerostomia caused by her medications can put her at a higher risk for caries. V. Evaluation

A. Can evaluate progress at 6-month recall appointment by assessing bleeding on probing, gingival inflammation, plaque score, xerostomia, gingival health and periodontal status. B. Perform comprehensive periodontal exam by probing to re-assess periodontal status. Re-evaluate 5 mm pocket on #3 ML. C. Inquire if bite wing radiographs are needed. D. Follow up with patient about her brushing and flossing habits. Follow up to see if patient is complying with use of floss picks to clean tight contacts and the use of biotene mouth rinse. References Wilkins, E. M. (2017). Clinical practice of the dental hygienist. Philadelphia, PA: Wolters Kluwer. Wynn, R. L., Meiller, T. F., & Crossley, H. L. (2016). Drug information handbook for dentistry: Including oral medicine for medically-compromised patients & specific oral conditions. Hudson, OH: Lexicomp.