Tx Plan 1

Jessica Fox

L.

a. b.

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Preliminary phase Patient lnterview i. "l would like my teeth cleaned. I want to get my dental care under control" MedicaUDental History i. Medication 1. Albuterol- Oral effects; Xerostomia 2. Alprazolam - Oral effects; Significant xerostomia and salivary

Assessment

changes

3.

ii.

iii,

c. d.

e.

Symbicort - Oral effects; Xerostomia and localized Candida or Aspergillus infection. Does not receive annual dental exams. Last appointment was approximately 11 years ago. Flosses rarely. Brushes one time per week' Only receiving fluoride in drinking water. Currently using non-fluoridated toothpaste as he feels fluoride lowers lQ level. Asthma, chronic bronchitis, gout, sleep apnea,.xerostomia (from

CPAP/medications). Social HistorY i. Heavy snacker - Consumes a frozen pizza as a typical snack Vital Signs i. BP 150/90 - Consulted for ok to treat. Patient *425#' lnstructor gave ok to treat. lntra/Extra Oral Exam i. TMJ - deviates upon closure. Minimal popping associated bilaterally. No pain associated, ii. ChaPPed LiPs iii. Dry mouth - seen bilaterally on cheeks. Has a cheek bite look. iv. Tongue - Tan coating Present v. Mandible - Bilateraltori present vi. Extrinsic staining - Light yellow vii. Color of Gingiva - generalized red viii. Contour of lnterdental Papilla - localized blunted and bulbous in the posterior. Localized pointed and normal in the anterior. ix. Contour of Marginal Gingiva - Generalized knife-edged. Localized rolled in the posterior.

x. Consistency of Gingiva - Localized firm and resilient in the anterior'

f. B.

xi. xii.

Localized spongy and edematous in the posterior. Texture of Gingiva - Generalized stippled BOP

- Spontaneous

Periodontal exam i. Generalized 2-4 mm probing depth ii. Localized 5 mm on mesiofacial of tooth #6 and distofacial of tooth #3 Radiographs

2.

i.

Generalized horizontal bone loss DH Diagnosis - Phase 1 a. Level of Health i. Patient is in fair-poor health. Physically capable of good OHl, but Lacks knowledge and motivation to make and implement appropriate homecare. ii. Orally - Generalized gingivitis, localized slight in posterior. Class B calcu lus.

b.

3.

4.

5.

Diagnosis

i.

Generalized Gingivitis. Localized Slight (posterior)

Plan

a.

Consultation - No need for consult at this time - No need for phase 2 at this time. i. Previous filling on tooth #30 done the morning of the cleaning. b. Treatment Goals i. Less calculus, less BOP, Better OHI- Educate patient about his levelof dental health and options to improve it. Develop new routine of using new Oral B brush once daily along with a fluoridated toothpaste. Better nutrition - eliminate frozen pizzas as snacks, drink more water and eat more protein and green veggies. Maintain perio case type. c. Address phase of treatment i. Listed throughout plan Implementation * One DHYG appointment needed. a. Consultatircns, instruments used, homecare aids, anesthetic, prescriptions i. No consultation needed at this time. ii. Probed FM with UNC 12 probe. Ultrasoniced FM, followed by hand scaling FM with Sracey curettes (L12, tt/12, L3/!4],, sickle (H5/33), LtlL2 explorer. Followed hand scaling with slow speed prophy angle and medium paste, Applied fluoride varnish to FM. iii. Dispensed floss reacher (pt, had difficulty reaching the posterior teeth when flossing). Also dispensed floss pick and fluoride toothpaste. Evaluation - Phase 4 a. How will you evaluate care? i. Gingival bleeding decreased, gingival inflammation reduced, healthier gingiva present. b. Follow up charting i. Perio chart - Probing depths maintained c. Radiographs i. Bitewing Radiographs t, Bone loss maintained 2. CMS and Pan just done L month ago, so will need to wait until 1 year recall appointment to evaluate radiographs. d. Pt. OHI behavior changes i. Plaque score improved

ii. e.

iii.

Utilized recommended aids (Oral B brush used at least Floss reacher, Floss pick, and fluoride paste). Pt demonstrates appropriate use of aids.

l

time per day,

References

i.

ii.

Wynn, R. (2017). Drug information handbook for dentistry. Wolters Kluwer. Wilkins, E. (2017). Clinical practice of the dental hygienist. Philadelphia, PA. Wolters Kluwer.

Jts'*no Grading Criteria

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Assessesment

patient interview medical/dental histogy social history vital signs

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Gingivitis Periodontal Disease Caries

III. Plan

fV. Implementation (narrative section) Consultations, Instruments used Methods, Homecale Aids Anesthetic, Prescriptions

V. Evaluation How will you orhow did you evaluate care

Other Items References

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Total Final Score

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