PERIODONTAL MAINTENANCE POST-CARE PLAN TEMPLATE

Patient Name: Age:

Date of initial exam:9/28/2022 Date of post-perio (fall semester): 11/16/2022
Date of periodontal maintenance visit(s) : 4/14/2023

*All information documented should be used to evaluate patient’s periodontal disease status,
risk, prognosis, and individualized treatment/ education needs. Patient findings should be corre-
lated to the multi-factorial periodontal disease process, including- systemic and local risk fac-
tors, progression of disease, healing potential, management of disease, and prevention of recur-
rence. Failure to evaluate and correlate patient findings to the periodontal disease process, will
constitute loss of points.
1. Medical History Updates: (include systemic conditions altering treatment, pre-medication,
medical clearance) explain steps to be taken to minimize or avoid occurrence, effect on pe-
riodontal diagnosis and/or care. Compare to last semester and note any changes or up-
dates

BMI: 22 (NORMAL)
My patient’s body mass index is considered normal. Falling under overweight, would put my patient at
risk for a higher chance of periodontal disease, and a possibility due to systemic factors. Despite the
fact that my patient has no systemic factors that would possibly interfere with his oral health, it is im-
portant to educate him why his BMI could affect his progression of periodontal disease. Obesity can
put the heart at risk, increasing the chance for diabetes and even cancer, which would increase the
chance and quickly progress periodontal disease.

Last physical in July of 2022

Allergies: He is still allergic to peanuts and shellfish. Having a healthy diet and avoiding cariogenic
foods, will assist my patient to stay in the low-risk caries side. Although peanuts would be a good
snack with the least cariogenicity, I have recommended other foods that he could snack on to avoid
the chance of dental caries.

Alcoholic Beverages: My patient still drinks alcohol once a week, which increases his chance for xeros-
tomia and systemic diseases or complications such as liver damage and xerostomia. These complica-
tions would then increases his chance for periodontal disease and dental caries.

Smoking: My patient has been vaping for the last two years and explained that he has tried to stop
twice in the past. He quit smoking/vaping nicotine in March of 2023 and is using cessation aids such as
nicotine gum to deal with cravings. Smoking automatically and severely increases his chances for peri-
odontal disease. That reoccurring heat every hour could be an explanation for the loss of alveolar cre-
stal bone on the mandibular anteriors.

Employment: He is a 22 year old who is a full-time college student and still a student worker for
Lamar. His busy schedule could be a possible reason for the lack of oral care and his environment
could be the possibility of occasional drinking and smoking on the weekends.

Vitals: His pulse, breathing, and temperature was within normal limits except for his blood pressure.
His most recent visit was his first time I recorded an elevated blood pressure of 124/76. I advised my
patient to keep an eye on his blood pressure and take recordings everyday in case it worsens and
leads to systemic disease.

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

My patient’s last dental visit was in November of 2022 and had a deep dental cleaning done. He has
not had any issues with previous dental treatment and states that he would like his teeth to be whiter.

He stated that his gums don’t bleed when he’s brushing or flossing anymore which indicates that there
is progression of healthy tissues with zero bleeding by keeping up with his oral hygiene practices at
home.

He is sensitive to sweets which is a good thing. The usual sweets contains lots of sugars and cariogenic
ingredients that can put him at higher risk for dental caries.

He still grinds his teeth at night which explains the excessive amounts of wear facets and attrition on
his posterior teeth. This can later possibly cause temporomandibular joint disorder, which is why the
dentist and I referred the use for a night guard to prevent this complication later. The referral was
noted for his night guard by Dr. Seale.

I would consider his Dental I.Q to be pretty high now. He is aware of the importance of brushing and
flossing understands why his gums may be inflamed and cause bleeding. He is fully aware of his peri-
odontitis and why his staging and grading is the way it is. He is eager to improve more on his oral
health and how to prevent his progression of periodontal disease.

His plaque score was considered fair (0.16) and his bleeding score was 0%. When brushing during his
visit, I noticed his technique I showed him during his last visit. A 45 degree angle along the gum-line
will remove buildup and plaque accumulating under the gums. I also noticed he was still missing spots
to brush on his mandibular anteriors. Because of this, the use of his lingual retainer was serving more
as a retentive feature, progressing his periodontal disease. He was now aware on how to floss with his
retainer. He is still using a soft manual toothbrush and brushes twice a day, once in the morning and
once at night. He is now flossing every now and then, and continues to use mouth-rinse daily in the
mornings.
3. Extra/ Intra-oral and Dental Examination Updates: (lesions noted, facial form, habits and
awareness, consultation) and (caries, attrition, midline position, malpositioned teeth, occlu-
sion, abfractions). Compare to last semester and note any changes, updates, and effects on
perio.

TMJ bilateral clicking was examined on my patient. He has no headaches or any other complications
that may bother him from this. The dentist told him that if he ever felt any pain on tenderness, to visit
an oral surgeon.

The patient grinding at night resulted in his wear facets and attrition on the posterior teeth. A night
guard was recommended to prevent further attrition and possible TMJ complications when grinding at
night. Grinding and bruxism can lead to fractured or chipped teeth, worn enamel, increased sensitivity,
tight jaw muscles, or even a locked jaw. The constant pressure on the teeth can lead to widened PDL
and possibly damage the teeth and the periodontium

He has an end-to-end bite. His occlusal examination was a three all around. No overbite or over-jet
was found but a midline shift was noted 3 mm to the right.
4. Periodontal Examination: (color, contour, texture, consistency, etc.)
a. Prophy Class: 3 Periodontal Stage & Grade: 2A
b. Gingival Description:
Last semester:
The patient has localized festoons on the lingual anteriors as well as redness and edematous
tissue on the same area. The same localized area consisted of rolled margins and bulbous
papillae. No suppuration or exudate was found. The papillary and marginal surface texture
was generalized smooth and shiny and the surface texture of the marginal gingiva was gener-
alized stippled. This data gathered is a clear sign of inflammation and it’s important to explain
to my patient what the tissues and its surroundings are supposed to look like when healthy. In-
flammation is caused by bacteria and buildup, which causes gingivitis, which then causes peri-
odontitis when cared for infrequently. Removing the calculus and reducing the inflammation
will decrease the progression for his periodontal disease.

This semester:
His gingival health overall was very little edematous and generalized redness. He had a local-
ized area on the mandibular anteriors that consisted of rolled margins and normal papillae. No
suppuration or exudate was found. The papillary and marginal surface texture was general-
ized smooth and shiny and the surface texture of the marginal gingiva was generalized stip-
pled. This data gathered is a clear sign of improvement in tissue health to prevent progression
of disease.

c. Plaque Index: Appt 1: .16/ Good

d. Gingival Index: .5/ Good
e. Bleeding Index: Appt 1: 0%
f. Comparison of indices from last semester to now & relationship to perio:

An ideal plaque index falls under 0-1.7.

On my patient’s initial visit last semester, his index was at a .6 and his bleeding at a 10%. The
second appointment was .16 and 8% so we saw improvement in plaque index and slight im-
provement in bleeding. The third, fourth, and fifth appointment were all .16 plaque and 2%
bleeding index.
This semester for his post-perio visit, his index was .16 and 0%. These indices show how con-
sistency in a thorough oral home care shows improvement on his overall oral health. His in-
dices in the his initial visits correlated his gingival inflammation and overall bleeding scores.
He reached a long term goal due to his bleeding score this semester being at 0%. Improve-
ment shows the halting or periodontitis and reduction in bleeding which ties with inflammation
of the gums (gingivitis)

5. Periodontal Chart: (Periodontal Maintenance probe depths, recession, and CAL assess-
ment findings- what do these findings indicate regarding the patient’s periodontal status?)

Last semester my patient had generalized 3-5 mm pocket depths. This semester he had 3-5
mm but they were only a few teeth (5) compared to last semester. His recession did worsen
on the mandibular anteriors and pre-molars in both arches but that’s due to the healing of the
tissue and it becoming tighter and compact. His highest CAL last semester was 5mm and this
semester it was 4 mm. This shows improvement in his periodontal status and we can see and
hope that there is no further progression of his oral disease.
6. Treatment and Patient Education: (Include all treatment provided and detailed account of
patient education session)
Appointment 1:
4 hour appointment
Covid 19 screening form
Pre-rinse
Update Med/Den Hx
Statement of Release
BWX: Check for caries
Head and Neck/ Intraoral Exam
Periodontal Assessment
Dental Charting w/ XRAYS
Risk Assessment
Informed Consent
Plaque score: .16/ Good
Bleeding score: 0%
Ultrasonic all 4 quadrants
Fine scale all 4 quadrants
Plaque free
5% fluoride Varnish
Referrals: night guard
Localized slight periodontitis with no bleeding
Recall for July 2023

Patient Education: Welcomed and introduced patient to the session. Reminded him of why this
education is important to improve his oral health. Started reviewing all topics from previous se-
mester which consisted of brushing, plaque, periodontitis, gingivitis, flossing with threader, and
tobacco cessation and the effect of smoking within the oral cavity. Asked open ended ques-
tions and patient replied with appropriate answers. Provided feedback for oral home care and
reviewed on typodont before disclosing the patient for his demonstration at home. Modified
any techniques and gave feedback and motivation to the patient. Reviewed CAL comparison
chart and focused on areas where we saw improvement. Reviewed recall date and referral for
night guard. Explained purpose of recall date and why it’s important to return for his 3-month
routine cleanings. Went over transtheoretical model and set learning level. Congratulated the
patient on improvement and for reaching specific goals
7. Prognosis: (Based on attitude, age, number of teeth, systemic health, malocclusion, peri-
odontal examination, maintenance availability)

Based on all the following points and my patient’s attitude this semester, I believe his prognosis is
great. He is young and his on his toes to really better his overall oral health. He has no underlying
conditions or complications that may prevent his advancement and improvement in oral health.
He has all his teeth and based on his prognathic occlusion, he’s at risk for excessive buildup for
food to be more retentive. I know his prognosis is great for a fact because when he returned for
his post-perio appointment, he asked for more floss threaders. This puts him in the termination
stage, halting progression of periodontal disease. This made me feel like I did a great job at edu-
cating him on the importance on his oral health and how it may correlate with systemic health. He
is really interested and encouraged to terminate his progression of disease. He is available for his
recall appointment date and seems more motivated to keep up with his oral health.

8. Supportive Therapy, patient attitude and response: Suggestions to patient regarding

re-evaluation, referral, and recall schedule. Patient’s attitude and level of cooperation towards
periodontal maintenance therapy and recall.

Suggestions given to the patient were to continue brushing and flossing as advised and to return for
recall appointments to improve his oral health. I suggested to continue to work with me, as a team,
to remove all plaque and calculus that may cause inflammation, tissue color changes, or progres-
sion of disease. We discussed night guard referral the dentist advised for proper care of the cavity. I
suggested his recall date based on his staging and grading of periodontitis to July 2023 and he
agreed to return for his routine cleaning. Patient was cooperative and is motivated to continue with
routine 3-month visits.
 9. Assessment of Changes and Goal Progress:
a. Describe changes since post-perio such as plaque control, bleeding tendency,
gingival health, probing depths, patient oral hygiene habits
During my post-perio evaluation I noted a decrease in his plaque score. On his first visit, it
was at a .6 and on his post-perio he improved to a .16. His bleeding index also im-
proved from 10% and down to 0%, reaching a long term goal we had set. His gingival
health was overall was very little edematous and generalized redness, but definitely im-
proved as to compared from his initial visit at our clinic. I congratulated my patient on his
improvement in tissue health because with this information, he was able to prove to me
that he was keeping up with his oral care at home. His probing depths overall decreased
in amount. He had very few teeth with 4 mm pockets as compared to last semester with
4s and 5’s. During patient education, he demonstrated brushing and flossing and he has
continued to use the 45 degree angle we had discussed last semester. With flossing, he
demonstrated a C-shaped as he went up and down each surface of the teeth.

b. Which goals from patient’s nonsurgical periodontal treatment (fall semester) did
the patient achieve?
My patient achieved his long term and short term goals from his first topic, which con-
sisted of brushing and plaque. He reached his long term goal by maintaining a plaque
score under .2, and he was at a .16. Within his short term goals, he understood the topic
of plaque and the brushing method. Within his second topics, he reached all goals by
understanding periodontitis and reaching a bleeding score of 0% by his post-perio ap-
pointment. He perfectly demonstrated the flossing technique, as well as using the floss
threaders to remove plaque under his lingual retainer. He also reached all long term and
short terms goals from his third topic by not vaping anymore and him explaining the ef-
fects it causes in the oral cavity. I asked him to name a few tobacco cessations supple-
ments and he said he had been using nicotine gum when he has a craving.

c. Which goals did they not achieve and why?

My patient has reached all long and short term goals we had set for him. He main-
tained a bleeding score of 0%, maintained a plaque score under .2, and quit
vaping. I am extremely proud of my patient and he had demonstrated all tech-
niques we had reviewed the previous semester. I advised my patient to con-
tinue using those techniques at home to maintain those indices within our
goal.

10. Self-Assessment: What did you feel that you did well with the patient? What improve-
ments could be done? Were there any topics that you would have addressed differently?
How? Include any other reflections you have toward the periodontal patient experience.
I feel that my patient gained an extensive amount of information. Comparing his oral health
from when he first walked into our clinic last semester to now, he was unaware that the
buildup in his retainer was actually calculus. I provided intraoral images to educate my patient
and he was on top of it answering any open-ended questions I had asked to challenge and
test his knowledge. He did not have a full understanding of what plaque was or how it can
mineralize to calculus or how to properly brush. He was unaware that you could use floss
threaders to get the floss under his retainer. I believe that I delivered every topic to the best of
my ability. My patient reaching his goals and improving his plaque and bleeding indices,
proved that I was delivering these topics in a proper manner. This being said, I don’t believe I
could have addressed the topics any differently. I am grateful to say that this experience with
my periodontal patient was beneficial to both me, and my patient. As a dental professional, I
am able to properly educate and assist my patients in reaching their oral health goals. To-
gether we are able to halt the progression of periodontal disease.