Special Needs TX Plan

Special Needs Tx Plan
Kendre Kamm
July 17, 2018
Assessment:
A. Minor sensitivity to cold & sweets occasionally, areas of food impaction on the lower
mandibular teeth #28-29, pt experiences dry mouth due to medications but stated it’s time to
have her teeth cleaned because she can’t do a very good job herself.
B. Patient has had previous extractions of 3rd molars and #15, 18, 31. Pt has 25 teeth total.
Pt frequently has ulcers throughout the mouth from GERD. She seemed happy to be at her
appointment and has no history of bad dental experiences but stated she has had a lot of work
done over the years.
a. Medications:
i.Lovastatin (40 mg) for prevention of coronary artery disease, slow progression of coronary
atherosclerosis; can assess unusual presentations of muscle weakness or myopathy resulting
from lipid therapy.
ii.Omeprazole (40 mg) used for short term tx of erosive esophagitis due to acid-mediated GERD;
can cause taste perversion, xerostomia, esophageal candidiasis, & mucosal atrophy (tongue).
iii.Calcium (600 mg) dietary supplement to prevent calcium deficiency; no dental effects.
iv.Lisinopril (10-12.5 mg) to control high blood pressure; use caution when changing positions
during or after dental tx.
v.Latanoprost (eye drops) used for reduction of elevated intraocular pressure (IOP) in pt’s with
open-angle glaucoma and ocular hypertension; no effects on tx.
vi.Leflunomide (20 mg) for tx of adults with active rheumatoid arthritis; can cause xerostomia,
stomatitis, oral candidiasis, abnormal taste, enlarged salivary glands, esophagitis, and gingivitis.
C. Pt has severe rheumatoid arthritis and her hands are very swollen and painful. She has
a difficult time brushing and flossing her teeth due to immobility of her hands from active RA,
gripping a toothbrush is extremely difficult because of the severely inflamed joints.
D. Pt stated that she has family history of rheumatoid arthritis and remembers her
grandmother and grandfather both were affected by RA. Patient does not smoke or drink.
E. BP: 112/64
F. Extra Oral: wears glasses because of glaucoma,TMD slightly more pressure on left side
and clicking on both sides. Intra oral: single minor lesion on hard palate 1 mm in diameter, (pt
says it has may have been from eating tortilla chips), coating of the tongue, bilateral mandibular
tori, bilateral linea alba, minor chapped lips solar cheilitis. Plaque score: 47%. Perio case type:
GEN Slight, LOC Gingivitis. Calc Class: B. Occlusion: Class 1 R & L
G. Periodontal probing measurements are stable ranging from 2~4 mm. Bleeding on
probing spontaneously.
H. Pt seems to have severe dry mouth & explained that dry mouth is common for her from
her meds. GEN erosion & recession. LOC attrition on lower anteriors. Slight rotation of lower
anteriors.
I. Radiographs on file: CMS from 2016. Visible bone loss present on radiographs and
multiple restorations present.
DH Diagnosis (Problem Identification)
A. Oral health: Fair. Physical health: Fair
B. Gingivitis (visible redness of gums in isolated areas of the mouth, bleeding present)
could be due to multiple medications pt is taking with side effects of increased risk for gingivitis
and poor oral hygiene from RA.
Plan
A. Comprehensive exam with general dentist and appointment with preventive clinic to
complete prophy.
B. Want to see a halt in progression of recession and plaque build up through better home
care & over all oral hygiene, decrease bleeding and inflammation of the gums, and less
interproximal biofilm/debris.
C. No extensive further treatment necessary.
D. Preliminary phase: assessment (review pt. history, medical/ dental history, obtain vital
signs, & perform full extra-intra oral exam)
E. Phase 1 Therapy: Dental biofilm and plaque control, Biotene mouthwash, electric
toothbrush with thick handle, dental floss threader, FM plaque & calculus removal. Restore teeth
esthetically.
Implementation:
A. Comprehensive exam with general dentist to screen for possible caries and appointment
to complete prophy with preventive/ dental hygiene clinic. Updated periodontal exam, oral
hygiene instruction needed.
B. Universal Sickle Scaler (2O4S, for any tenacious anterior calculus), area specific
Curettes (Gracey 1/2, 11/12, 13/14), universal curette (Columbia 13/14), Periodontal Probe,
mouth mirror, Discoid-Cleoid (for heavy plaque removal and stain).
C. Hand scale full mouth and polish to complete prophy.
D. Discussed the use of an electric toothbrush or a foam grip auxiliary aid to make it easier
to hold the toothbrush since having a firm grip can come as a struggle due to the severe arthritis
on the hands. Recommend Biotene mouth rinse to use at home for dry mouth aid, demonstrate
BASS brushing technique with soft bristle toothbrush because of her recession and inflamed
tissues. Recommended using a floss threader because of the thicker/bigger handle to hold but
may need assistance threading the floss, super floss may be easier with the floss being thicker
and easier to get a hold on.

E. No anesthetic needed.
F. No prescriptions needed.
Evaluation:
A. Based off patients clinical findings (refer to: plaque score, calculus, radiographs &
probing depths) and over all presentation of her health and visually evaluating her body
language.
B. Disclose and develop new plaque score to look for improvement and calculus detection.
Full mouth periodontal probing at every appointment following to monitor any progress.
C. Take updated radiographs: CMS or 4 vertical bitewings to see if bone loss is stable or
regressed.
D. Ask pt to demonstrate their homecare habits to see if it is still correct technique and
discuss how brushing is going with arthritis, always follow up with how she is feeling overall and
if there are any concerns. Pt understands that good oral hygiene is critical for improvement.
References
Wilkins, E. M. (2017). Clinical practice of the dental hygienist (12th ed.). Philadelphia:
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 (22nd ed.). Hudson, OH: Lexicomp.
Hebl, L. (2017) Oral Pathology Powerpoint

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Special Needs Tx Plan

July 17, 2018

done over the years.

atherosclerosis; can assess unusual presentations of muscle weakness or myopathy resulting

from lipid therapy.

during or after dental tx.

open-angle glaucoma and ocular hypertension; no effects on tx.

gripping a toothbrush is extremely difficult because of the severely inflamed joints.

GEN Slight, LOC Gingivitis. Calc Class: B. Occlusion: Class 1 R & L

multiple restorations present.

DH Diagnosis (Problem Identification)

A. Oral health: Fair. Physical health: Fair

and poor oral hygiene from RA.

C. No extensive further treatment necessary.

signs, & perform full extra-intra oral exam)

hygiene instruction needed.

mouth mirror, Discoid-Cleoid (for heavy plaque removal and stain).

C. Hand scale full mouth and polish to complete prophy.

and easier to get a hold on.

dentistry: Including oral medicine for medically-compromised patients & specific

oral conditions (22nd ed.). Hudson, OH: Lexicomp.

Hebl, L. (2017) Oral Pathology Powerpoint

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