TX Planning Assignment 2

I.
Assessment
 Patient Interview
o 60-year-old, white, male, 6’ tall, 190 lbs.
o Chief complaint: calculus deposits
 Medical/dental history
o Comes in every 6 months for cleanings, brushes 2-3 times daily, medium bristle
brush with scrubbing motion, fluoridated toothpaste, flosses daily
o Former smoker
o Wears glasses for vision loss, possibly needs hearing aids for hearing loss
o Has a primary care provider, gets cluster headaches, has high blood pressure, had
hernia surgery 24 years ago
o Medications
 Amlodipine: gingival hyperplasia, xerostomia, orthostatic hypotension,
erythema multiforme
 Ramipril: orthostatic hypotension, a dry cough that can hinder longer
dental procedures
 Omeprazole: taste perversion, mucosal atrophy, dry mouth, esophageal
candidiasis
 Ibuprofen OTC: prolonged bleeding times
 Social History
o Sales representative, travels for work most of the time
o Married, has adult children who live out of state

o Sucks on lemon lozenges
 Vital Signs
o BP 140/88, Pulse 70, Respirations 12
 EO
o Crepitus bilaterally (night guard at night)
o WNL
 IO
o Experiences aphthous ulcers on lips, gingiva, and tongue lasting 7-14 days. Began
when he stopped smoking and because consuming lemon lozenges (none present
at appointment)
o Painless circumferential redness in mucosa above tooth #3 (doctor diagnosis it as
a vascular hyperemia)
o Gingiva: GEN pink, LOC inflamed on mandibular lingual surfaces
o 25 total teeth
o Supragingival calc on mandibular, lingual anterior
o Bleeding index 20%, Plaque score 25%
o Overjet
 Periodontal exam
o Probing depths GEN 1-3mm with LOC 4-8mm on 2nd molars
o Recession LOC 1-3mm on maxillary facials
o CAL GEN 2-3mm with LOC 4-6mm on 2nd molars and facials of maxillary teeth
 Radiographs
o CMS provided, WNL
II. Diagnosis
 Level of health
o ASA PS III
 He presents with Periodontal disease
III. Plan
 Consultations needed
o Consult primary care provider assessment to control hypertension
o Consult with periodontist
 Tx goals
o Reduce plaque score, bleeding, plaque and calc
o Maintain probing depths without progression of periodontal disease
o Reduce aphthous ulcer frequency of occurrence by reducing lozenge consumption
 Preliminary phase
o Stabilize stage II periodontal disease
o High frequency of aphthous ulcers
o Improve plaque and bleeding scores, reduce inflammation of mandibular anterior
lingual tooth surfaces
o Adjustment for medications: ensure adequate bleeding times, raise chair slowly to
prevent orthostatic hypotension, ask about dry mouth, inspect tissue during IO
and document anything out of the ordinary,

o Patient’s goal is to have calculus removed from his teeth. Advise patient to
maintain home care routine with instruction on how to properly brush and floss
 Phase 1 (initial therapy)
o Plaque and calculus removal by SRP Tx – use of ultrasonic and prophy
o Introduce preventative measures- provide OHI, encourage the removal of
lozenges from diet
 Phase 2 (surgical)
o Consult with periodontist
 Phase 3 (restorative)
o Discuss with dentist and patient the need/desire for removable or fixed protheses
for missing dentition
o No other restorations needed at this time
 Phase 4 (maintenance)
o 3-month recall
o Assess homecare (improvement/stability/decline) at recall appointment
o Reduce BOP, biofilm, inflammation
o Educate patient on home care importance and proper technique
IV. Implementation
 Consult primary care provider for high blood pressure medication and management
 Local anesthetic for SRP
 Home care aids: soft bristle toothbrush
 Radiographs taken in 6 months to evaluate periodontal disease for bone loss

 Will use ultrasonic, anesthetic, prophy (use fine polish), disclosing solution, floss, and hand
scalers for FM TX/ SRP
 Advise patient to use a soft toothbrush instead, begin brushing with the bristles pointed to the
gumline instead of just scrubbing the teeth. Advise brushing the gumline to stimulate blood
flow, remove bacteria, and reduce future bleeding. Advise patient to wrap floss around each
tooth to ensure he is fully cleaning under the gums to lower bleeding index. Advise against
eating lozenges all day to allow the mouth to rebound to the proper pH level.
 Recall appointment in 3 months
V. Evaluate
 Assess if probing depths and BOP have decreased
 Ensure OHI was effective by lower plaque scores, lower bleeding index, and lower
presence of calculus
 Ask about frequency of aphthous ulcers and updated diet habits
 Evaluate radiographs in 6 months to ensure periodontal disease has not progressed
References:
Wilkins, E. M., Wyche, C. J., & Boyd, L. D. (2017). Clinical practice of the dental hygienist.
Wolters Kluwer.
Wynn, R. L., Meiller,. T. F., & Crossley, H. L. (2021). Drug information handbook for dentistry:
Including oral medicine for medically compromised patients & specific oral conditions.
Lexicomp/Wolters Kluwer.

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I.

o 60-year-old, white, male, 6’ tall, 190 lbs.

o Chief complaint: calculus deposits

brush with scrubbing motion, fluoridated toothpaste, flosses daily

hernia surgery 24 years ago

 Amlodipine: gingival hyperplasia, xerostomia, orthostatic hypotension,

 Ramipril: orthostatic hypotension, a dry cough that can hinder longer

 Omeprazole: taste perversion, mucosal atrophy, dry mouth, esophageal

 Ibuprofen OTC: prolonged bleeding times

o Sales representative, travels for work most of the time

o Married, has adult children who live out of state

o BP 140/88, Pulse 70, Respirations 12

o Crepitus bilaterally (night guard at night)

o Painless circumferential redness in mucosa above tooth #3 (doctor diagnosis it as

o Gingiva: GEN pink, LOC inflamed on mandibular lingual surfaces

o Supragingival calc on mandibular, lingual anterior

o Bleeding index 20%, Plaque score 25%

o Probing depths GEN 1-3mm with LOC 4-8mm on 2nd molars

o Recession LOC 1-3mm on maxillary facials

 He presents with Periodontal disease

o Consult primary care provider assessment to control hypertension

o Consult with periodontist

o Reduce plaque score, bleeding, plaque and calc

o Maintain probing depths without progression of periodontal disease

o Reduce aphthous ulcer frequency of occurrence by reducing lozenge consumption

o Stabilize stage II periodontal disease

o High frequency of aphthous ulcers

o Improve plaque and bleeding scores, reduce inflammation of mandibular anterior

lingual tooth surfaces

and document anything out of the ordinary,

 Phase 1 (initial therapy)

o Plaque and calculus removal by SRP Tx – use of ultrasonic and prophy

o Introduce preventative measures- provide OHI, encourage the removal of

lozenges from diet

o Consult with periodontist

for missing dentition

o No other restorations needed at this time

o Assess homecare (improvement/stability/decline) at recall appointment

o Reduce BOP, biofilm, inflammation

o Educate patient on home care importance and proper technique

 Local anesthetic for SRP

 Home care aids: soft bristle toothbrush

 Radiographs taken in 6 months to evaluate periodontal disease for bone loss

scalers for FM TX/ SRP

 Recall appointment in 3 months

 Assess if probing depths and BOP have decreased

 Ask about frequency of aphthous ulcers and updated diet habits

 Evaluate radiographs in 6 months to ensure periodontal disease has not progressed

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