By developing a care plan for my patients, I am completing the core competencies of values and skills. Developing a care plan for a patient is beneficial in recording the progress of the patient and also implementing dental education which is further benefit the patient. This periodontal care plan is a detailed treatment plan for the patient. I believe the competencies I used to help develop this care plan were Health Promotion, Patient Care, as well as Professional Growth and Development. I believe I excelled in these competencies because I was able to promote health to my patient in terms of describing and teaching new dental hygiene methods as well as care for my patient and get them back to a state of dental health. This experience also allowed for professional growth by also teaching me more about periodontitis and how to care for a patient who is diagnosed with it. I believe my care plan visually shows that I am applying the knowledge I have learned and implementing it into a plan for a patient so that they can better their home care. While working on this assignment I discovered that I explain difficult concepts well and have the patience to ensure that a patient fully understands the new information they learn and how to apply it at home. I believe this assignment will help me in the future because I am equipped with the information and knowledge needed for caring for a patient with periodontitis whether it is severe or not. In developing a dental hygiene care plan I was required to collect data and provide a personalized treatment plan for my patient according to positive findings found during the appointment. Patient care and health promotion is a core competency that has been reached by creating care plans for patients.
As a future Dental Hygienist, developing care plans will be routine. It is important to assess as much information clinically of the patient as possible so that the care plan will further be more successful in the treatment process. Communication and rapport with the patient is essential in a successful care plan as well.
As a future Dental Hygienist, developing care plans will be routine. It is important to assess as much information clinically of the patient as possible so that the care plan will further be more successful in the treatment process. Communication and rapport with the patient is essential in a successful care plan as well.
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GINGIVAL INDEX
PERIODONTAL CARE PLAN
Initial date: October 5, 2015
Gingival Area
TOTAL: 1.75 GI/Fair
Final date: November 23, 2015
Gingival Area
TOTAL: 1.16 GI/Good
PERIODONTAL CARE PLAN
Patient Name: Patient Age: 46
Date of initial exam: October 5, 2015 Date completed: 11/23/2015
1. Medical History: (systemic conditions altering treatment, pre-medication, medical clearance) explain steps to be taken to minimize or avoid occurrence, effect on dental hygiene diagnosis and/or care.
2. Dental History: (past dental disease, response to treatment, attitudes, dental I.Q., chief complaint, present oral hygiene habits, effect on dental hygiene diagnosis and/or care)
Patient’s chief complaint for visit is for a “cleaning.” Patient feels “ok” about the appearance of her teeth/smile due to heavy staining from drinking a cup of coffee every morning. Her last dental visit was January 2015 for a restoration for caries and also a cleaning was involved. When asked about that dental office, the patient was unsure of the DDS name or the name of the office. The patient is unaware of any past dental diseases due to infrequent dental visits. Patient checked “yes” to having many cavities at dental checkups. She also stated that her teeth are sensitive to cold, which can signify exposed dentin and is a sign of periodontitis. The patient is experiencing sensitivity due to the recession that has taken place, which is the result of bone loss. When asked why she doesn’t attend routine dental recall appointments, patient explains that her regular dentist use to be Dr. Jerry L. Burd DDS and after her periodontal treatment at his office about 4 years ago that she did not feel the need to go back after a few recall appointments. The patient also does not have any dental insurance, which can also be another reason for the infrequent routine dental exams. Infrequent dental visits correspond with overdue professional dental cleanings that result in plaque and calculus accumulation. The patient explained that the last dental visit was in Houston and that was only for the restoration to be filled. The patient stated that she recently received bitewing x-rays at the last dental visit in January 2015. She does not remember taking a panoramic x-ray. She remembers taking a full set of 20 pictures, which is an FMX at her initial appointment at Dr. Burd’s office about 4 years ago. Minimum restorative fillings have been accomplished in the patient’s mouth, as well. Patient will be informed of the importance of maintenance recalls and how keeping up with her oral hygiene through routine cleaning along with her personal hygiene. The patient should be aware of the LIT recall program, and she should be advised to return every 3 months. Patient’s attitude to receiving a dental cleaning was eager, however her learning level at the initial appointment was unaware. Patient’s dental I.Q. is poor along with her dental baseline oral hygiene habits and she is also unaware of her periodontal disease. Patient uses a soft bristle toothbrush, and brushes two times a day with occasional bleeding on gums. Bleeding is a noticeable sign that infection is taking place. Bleeding is directly related to plaque (bacteria) accumulation that can result in periodontal disease, decalcification, caries, and calculus formation. Rinsing, fluoride and other home care aids are not involved for the patient currently. Patient says she flosses sometimes after eating. Not flossing allows the plaque to calcify subgingival and the bacteria is constantly attaching to the hardened plaque known as calculus. All of these oral hygiene habits are contributing factors that have slowly progressed the patient’s periodontal condition from gingivitis to a chronic, moderate form of periodontitis, or bone loss (Periodontal Case Type 3). The progression of inflamed gingival tissue with red, blunted and/or rolled margins and papilla are characteristics of gum disease. However, if the inflamed area of bacteria from the plaque covering the tooth is not adequately removed this will progress into the other stage of periodontal disease, termed periodontitis. Periodontitis is actual bone loss, which holds the tooth secure in the mouth. Progression of this disease could lead to more destruction in the future if not treated immediately causing mobility of the teeth and eventually loss of the tooth altogether.
3. Oral Examination: (lesions noted, facial form, habits and awareness, consultation)
During the extra oral examination, all that was noted was the patient’s generalized ephelides, which are flat lesions with the etiology of sun exposure.
During the intraoral examination, it was noted that the patient has a slight torus palatinus, bilateral mandibular tori, and bilateral exostosis, which are all developmental. The patient also had linea alba on the left side and the etiology is from cheek biting.
During the occlusal examination, the patient’s right molar and canine were both Class I occlusion, the patient’s left molar is Class III, and the left canine is Class I. The patient has an overbite of 1mm (WNL), an overjet of 2mm (WNL), and has no midline shift.
The patient does not have any open bites or cross bites.
4. Periodontal Examination: (color, contour, texture, consistency, etc.)
a. Case Classification: 4 Periodontal Case Type: 3
b. Gingival Description:
The patient’s periodontal assessment reads that infection is taking place within the gingival tissues. The patient’s plaque accumulation has caused an inflammatory response on the gingival tissues. To prevent further progression the patient should begin excellent home care methods (brushing, flossing, rinsing) to help reduce the bacterial load in his mouth, and prevent more gingival tissue disturbances and halt disease progression.
App't 1:
Architecture: Generalized scalloped architecture
Color: Generalized redness
Consistency: Generalized edematous/spongy consistency
Margins: Generalized rolled margins
Papillae: Blunted in the mandibular anterior teeth lingually and bucally
Suppuration: None
Surface Texture: Generalized smooth and shiny (including attached)
App't 2:
Architecture: Generalized scalloped architecture
Color: Generalized redness
Consistency: Generalized edematous/spongy consistency
Margins: Generalized rolled margins
Papillae: Blunted in the mandibular anterior teeth lingually and bucally
Suppuration: None
Surface Texture: Generalized smooth and shiny (including attached)
App't 3:
Architecture: Generalized scalloped architecture
Color: Localized redness anterior mand. lingual
Consistency: Generalized edematous/spongy consistency
Margins: Generalized rolled margins
Papillae: Blunted in the mandibular anterior teeth lingually and bucally
Suppuration: None
Surface Texture: Generalized smooth and shiny (including attached)
App't 4:
Architecture: Generalized scalloped architecture
Color: Localized redness anterior mand. lingual
Consistency: Generalized edematous/spongy consistency
Margins: Generalized rolled margins
Papillae: Blunted in the mandibular anterior teeth lingually and bucally
Suppuration: None
Surface Texture: Smooth and Stippled
App't 5:
Architecture: Generalized scalloped architecture
Color: Localized redness anterior mand. lingual
Consistency: Generalized edematous/spongy consistency
Margins: Generalized rolled margins
Papillae: Blunted in the mandibular anterior teeth lingually and bucally
Suppuration: None
Surface Texture: Smooth and Stippled
App't 6:
Architecture: Generalized scalloped architecture
Color: Localized redness anterior mand. lingual
Consistency: Localized edematous/spongy consistency mandibular molars
Margins: Generalized rolled margins
Papillae: Blunted in the mandibular anterior teeth lingually and bucally
Suppuration: None
Surface Texture: Smooth and Stippled
c. Plaque Index: App’t 1: 2.0/Fair 2: 2.0/Fair 3: 2.0/Fair 4:1.0/Good 5: .6/Good
6: .5/Good
d.Gingival Index: Initial: 1.04/Fair Final: 1.16/Good
e. Bleeding Index: App’t 1: 3% 2:3% 3:1.1% 4:1% 5:0% 6:0%
f. Evaluation of Indices:
1. Initial: The evaluations of the following indices are signs that play as contributing factors to the patient’s prognosis of periodontal case type III, chronic, moderate periodontitis. The patient has moderate generalize plaque with large amounts of accumulation taking place in the maxillary posterior facial and lingual area, as well as, the interproximal areas of the posterior teeth. The patient’s plaque accumulation is directly related to her gingival inflammation and bleeding. The indices are rated higher than normal because of all of the bacteria that is taking place in the mouth. If the patient continues to allow plaque accumulation then continuation of bone loss could possibly take place. The patient’s gingival index is 1.8 which is considered fair.
2. Final: The patient has slight generalized plaque.
-The patient’s plaque accumulation is directly related to the slight inflammation and redness continuing to take place in the mandibular molar area. The bleeding score has improved which is a result from the proper home care taken place with the patient. The patient’s indices scores are rated good (better than initial appointment). With the patient’s proper homecare and eagerness to get back to a healthy state, I believe she in improving better that expected.
g. Periodontal Chart: (Record Baseline and First Re-evaluation data)
1. Baseline: Patient has generalized pocket depths ranging from 3-8 mm in the posterior area of both maxillary and mandibular teeth, facial and lingual, with deeper 5 mm pocket depth readings on the mesial and distal in the posterior areas posterior teeth.
The pocket depth along with clinical attachment level measured by probe has indicated several areas of unhealthy pocket depths and/or loss of tissue attachment that are contributing factors to patient’s moderate form of periodontitis. With 3-8 mm pocket depth measurements in the posterior area of maxillary and mandibular teeth, this indicates an early sign of an unhealthy pocket depth that the patient needs to be educated and informed about to halt the progression of receding pocket depths, and in the patient’s circumstance a disease known as periodontitis. The areas with the worse clinical attachment loss would be in the molar region of the maxillary left and the molar region of the mandibular on both left and right. With the attachment loss ranging from 4-5mm, the patient needs to be referred back to her periodontist after treatment. Through adequate brushing and flossing, the patient can help her tissues regain attachment to the teeth, especially in areas where a 4-8 mm pocket depth was recorded on the mesial and distal areas of the maxillary left and mandibular right teeth. The patient has recession on #3, #11, #12, #13, #19, #20, #28, and #30. Also, with tooth #32 being mesially impacted towards #31, and a defective restoration being found on the DO of #31, these are both contributing factors to the patient’s periodontal disease state because the defective restoration can now harbor bacteria and begin attacking the tooth, which in turn affects the sulcus where the gums start to recede leading up to the attack of bone loss in the specific area where visible loss of bone is evident on the radiographs. The patient has class I furcation on tooth #3, and class I furcation on #19 and #30. With the furcation involvement, the periodontal infection invades the area between and around the roots, resulting in a loss of attachment and los of alveolar bone between the roots of the tooth. The patient has no mobility, suppuration, or sensitivity.
2.Firstevaluation: The patients periodontal charting did show to change in the 7mm pocket areas that reduced to 5-6mm. The patient continues to have pocket depths between 4mm and 6mm pockets in the mandibular third molar region. The patient continues to have 4mm pockets taking place in the mandibular anterior region. The patient continues to have generalized 1mm of attachment loss with 2mm of attachment loss in the mandibular third molar region. This is directly related to the horizontal bone loss that already took place in the mandibular anterior region on the patient’s radiographs. The patient has no mobility, suppuration, or sensitivity.
5. Dental Examination: (caries, attrition, midline position, mal-relation of groups of teeth, occlusion, abfractions)
6. Treatment Plan: (Include assessment of patient needs and education plan)
App't 1:
App’t 2:
App't 3:
App't 4:
App't 5:
App't 6:
Review medical/dental history, Acquire plaque and bleeding score, Assess gingival condition, Obtain final gingival index, Chair-side Patient Education: Importance of regular dental care visits, Explain to the patient the importance of regular dental exams and how keeping up with her oral hygiene can help halt the progression of her disease, Local anesthesia, Ultrasonic scale quadrant 4, Final periodontal charting, Fine scale. Referral to periodontitis is needed due to moderate periodontitis.
App't 7:
7. Radiographic Findings: (crown root ratio, root form, condition of interproximal bony crests, thickened lamina dura, calculus, and root resorption)
8. Journal Notes: (Record in detail the treatment provided, oral hygiene education, patient response, complications, improvements, diet recommendations, learning level, short and long term goals, expectations, etc.) The progress notes should be written by appointment date.
Appt 1 (October 5, 2015): Treatment: Reviewed medical and dental history, prerinse, intraoral and extra oral exams, periodontal assessment, dental charting, plaque score, bleeding score, FMX survey due to the clinical evidence of periodontitis. Education: Discussed plaque and sulcular brushing method. Patient Response: The patient seemed to be interested in the topic, and eager to get treatment. Complications: The patient has a smaller mouth than normal and tends to close easily. I used a mouth prop in order to continue proper treatment. Learning Level: unaware. Long-term goal was to reduce the plaque score and short-term goals is learning how to brush correctly and understand the importance of the disturbance of the plaque in the oral cavity. An important diet recommendation given to the patient was to avoid heavy coffee drinking to prevent stains and to lower sugar to prevent the cavity rate. The patient’s learning level is unaware at this appointment.
Appt 2 (October 12, 2015): Treatment: Reviewed medical and dental history, prerinse, finished complete periodontal charting, started inform consent and risk assessment. I took the plaque score and bleeding score and finished periodontal assessment. Education: The importance of flossing and how it can halt the progression of her disease. I also explained to the patient that we will be having patient education sessions at every appointment and will clean a specific area in order to understand the prevention measures along with treatment. The patience response is that she likes using floss picks only. I explained that we would further explain the importance in the correct methods in floss usage and her periodontal health in a further detailed patient education session. Reviewed all LTGs and STGs with the patient. The patient’s learning is aware at this appointment.
Appt 3 (October 19, 2015): Treatment: Reviewed medical and dental history, prerinse, took plaque score and bleeding score. Start the first scaling and ultrasonic in the mandibular right. Education: The formal first patient education session was taught to the patience about the importance of plaque destruction and the definition. Reviewed all LTGs and STGs with the patient. Explained to the patient to correct sulcular 45-degree angle brushing to remove plaque properly and efficiently. I also educated the patient with tongue brushing and to brush 2x/day for 2 minutes. The patient seemed very confident in reaching these goals due to that fact that she does brush that often per day, the only thing that we modified was her old method of brushing to the correct method. The patient was again recommended to avoid heavy drinking of coffee and teas. The learning level is at self interest by this appointment.
Appt 4 (October 30, 2015): Treatment: Update and review the medical and dental history, prerinse, take plaque score and bleeding score, and start scaling the second quadrant of the mandibular left. Education: The second patient education session was taught to the patient about definition of periodontitis and how it affects the oral cavity. Reviewed all LTGs and STGs with the patient. Flossing is essential to remove plaque in between teeth to prevent further bone loss. I taught patient the “C-method” of flossing. She was definitely having difficulty using the floss correctly toward that back areas of the mouth. With that I recommended her to use the floss picks in the back areas but to use the regular floss in the front and over time with practice she will be able to better her technique. The patient showed improvement in brushing due to the lowered plaque score recorded and attained all the STGs from the first patient education session. The patient’s learning level is at action at this appointment.
Appt 5 (November 2, 2015): Treatment: Review and update medical and dental history, prerinse, take plaque score and bleeding score, and start scaling/ultrasonic the third quadrant of the maxillary left. Education: I taught the patient about the caries process, the definition, and the prevention measures. Fluoride can play a huge role in her prevention and can be found in specific mouth rinses and dentifrices. Reviewed all LTGs and STGs with the patient. It was emphasized about the importance of routine care to halt the progression of her disease. The patients response to the fact she had cavities was very shocking to her due to the fact that she recently had restorative treatment and with my response again that it ties into the importance of regular dental care to be able to detect these cavities and to reduce any bacterial counts all go with routine care. The patient was able to attain the STGs in result of reduce bleeding score and the patient successfully demonstrated the correct flossing technique chair side. The patient’s learning level is at action at this appointment.
Appt 6 (November 9, 2015): Treatment: Review and update medical and dental history, prerinse, take plaque score and bleeding score, and start scaling maxillary right (last quadrant), flossed and plaque free. Education: Explained that the next appointment we will be apply arestin which is an antibiotic to the deep pockets in the mouth. Reviewed proper brushing and flossing and emphasized the importance in home care to successfully complete the treatment and to maintain health in the mouth. The patient did complete a LTG and decided to get in contact with a previous DDS to restore her cavities. The learning level at this appointment is involved and action.
Appt 7 (November 23, 2015): : Treatment: Reviewed medical and dental history, prerinse, plaque score, bleeding score, gingival index, sealants (#12, #4, #5, #13), full post perio charting, hand scaling full mouth to check for residual calculus, Fluoride gel, placed Arestin. Patient education: discussed STG and LTG, discussed Arestin and its importance as an antimicrobial in illuminating bacteria in pockets, re-demonstrated brushing on the typodont and has patient re-demonstrated at sink just to be sure of the correct technique and methods. Patient response: My patient was very interested in the Arestin she asked several questions regarding this topic. I also reminded the patient to avoid flossing in area for 7-10 days and gave her an informative packet regarded Arestin information. LL-Action. Complications: The only complication was probably applying the Arestin, but after the first one, it became easier to apply. The patient stated that she will return to Dr. Burd’s office for routine care which is a great goal she has reached.
9. Prognosis: (Based on attitude, age, number of teeth, systemic background, malocclusion, tooth morphology, periodontal examination, recare availability)
Overall Prognosis: Good
-I rate my patient a good prognosis because my patient does not have any systemic factors and patient is very cooperative and eager during overall treatment to go back to the healthiest state possible. The patient shows commitment and involvement. This is resulting in the reduction of plaque in the patient’s mouth every appointment. My patient has generalized 4 to 6 mm pockets that did improve by her post evaluation appointment which was a great improvement. My patient is 46 years old and has remaining functional teeth. My patient admits to cutting down on heavy coffee sugary drinks and limited herself to just one a day versus the multiple cups she had before. I rate my patient a good prognosis instead of fair or poor, because she had made multiple efforts to improve her oral health, including making an appointment to go back to her periodontitis. The patient is self employed which means she is able to make recare appointments easily with the clinic or her periodontitis. This shows me as her health profession that she is more than serious about her health and the only thing that was preventing her was the proper education. The patient’s malocclusion is in a good state where there aren’t areas of heavy plaque retention.
-Prognosis for individual teeth- #31L and #30L (fair) have 6-7 mm pockets allowing a possible environment for gram – bacteria to accumulate and breakdown the periodontium resulting in loss of attachment and further complications but during the post evaluation that was a reduction in pocket depth. #14 and #32 (fair) has occlusal carious lesions. These carious lesions could provide an environment for gram – bacteria to accumulate but that patient has already stated she will be getting these restored so after they do I believe they will be in a good state. I rate all of the above teeth as fair due to the fact that they will be corrected soon by a dental care professional.
10. Supportive Therapy: Suggestions to patient regarding re-evaluation, referral, and recall schedule.
I explained to my patients the results of the re-evaluation appointment. I explained that with her proper home care methods that there is an improvement of gingival and periodontal pockets. I praise the patient on how great she has been doing and encourage her to continue the home care even after treatment to maintain a healthy oral cavity. I recommended the patient to use floss aids in order to get into the molar areas since she was having difficulty using regular floss. Referrals that my patient had are for carious lesions on #14 and #32. With my constant reminders, my patient has decided to return to her periodontitis for regular treatment. As for her re-evaluation, I put her down for a three-month recall-February 2016.
11. Assessment of Changes: (including plaque control, bleeding tendency, gingival health, probing depths)
Plaque control- Overall by reviewing the plaque indices the patient shows improvement of plaque control, which shows that she is successful in completing proper home care.
Bleeding tendency- Overall by reviewing the bleeding indices my patient did show improvement, which can conclude from proper flossing techniques being used.
Gingival Health- overall my patient’s gingival health improved tremendously. My patient gingival index had decreased by .59. The reduction is most likely related to heavier plaque accumulation in the beginning of treatment. The redness and inflammation were slight.
Probing depths- My patients probing depths did change by her post evaluation appointment in a few areas. The patient continued to show generalized 4-6mm pockets in the third molar region, but with some of the heavier 8mm and 7mm pockets were reduced to 5-6mm. I believe this is the result of proper oral hygiene and with other areas may need attention from a periodontitis.
Statement- Overall, my patient has improved greatly in areas of plaque and gingival health. If my patient continues the proper home care and starts to get back into her routine dental care, the full halt of her disease can be reached which is the main goal in our treatment.
12. Patient Attitudes and Cooperation:
My patient’s attitude was as positive and attentive. At each appointment, my patient was prompt and came in with an eager and motivating attitude. Once I started explaining to her the severity of her disease, she was more than willing to get treatment and was eager to be at the clinic. She has a few difficulties understanding specific processes such as her periodontal disease and the caries process, but with constant patient education and chair side education; she had further understood the information. Overall, I feel blessed to have such a patient person in my chair because she was very calm and attentive. Throughout her treatment, her bleeding score and plaque scores were reducing which showed she was very effective in her homecare.
13. Personal Evaluation/Reaction to Experience:
For me this was a great learning experience. I must admit that this was a difficult challenge at first, but completely worth it in the end. I have learned so much from this periodontal case and the periodontology class. During this project I found myself contributing more time and effort to the gingival tissues and how to determine healthy vs. unhealthy. I had a saying that I told my patient at every appointment, “A Healthy Mouth Never Bleeds.” That statement led her to be more motivated in home care and preventing any type of bleeding regardless if it was during brushing or flossing. It was amazing to see the gingival tissues transform week-to-week and knowing what was taking place. This was the first patient I have ever had the opportunity to recognize a change in tissue and understand what was occurring. I was also very pleased at how involved my patient was in restoring her oral health to the healthiest state possible. I find it fascinating how disease progression takes place in the mouth. It was very beneficial for me to have this assignment because not only did it further educate me with periodontitis but also it truly helped me through lecture because all of the information coincides with our treatment plans with our patient. The specific subjects I learn in class help me further educate my patient in every way possible.
Patient Education
PERIODONTAL CARE PLAN
Initial date: October 5, 2015
Gingival Area
TOTAL: 1.75 GI/Fair
Final date: November 23, 2015
Gingival Area
TOTAL: 1.16 GI/Good
PERIODONTAL CARE PLAN
Patient Name: Patient Age: 46
Date of initial exam: October 5, 2015 Date completed: 11/23/2015
1. Medical History: (systemic conditions altering treatment, pre-medication, medical clearance) explain steps to be taken to minimize or avoid occurrence, effect on dental hygiene diagnosis and/or care.
- Patient currently has no medical problems that will complicate her dental treatment. No allergies are present and the patient is not on any type of medication(s). Patient currently does not have a physician and her last physical is not applicable. Without the care of a physician or a current physical, she will not be aware of any acute and/or chronic systemic conditions that may have occurred or is currently present within her body without a proper physical completed. Systemic conditions such as asthma, diabetes, or even cancer are a few of many possibilities that the patient may not be aware with until multiple complications or emergent care is needed. There are many issues that may take place with the body that contribute to periodontal disease. If these issues go unnoticed or neglected than the consequences can affect the oral cavity, as well as, the patients over all health. For this reason, the patient should be encouraged to receive a yearly physical to ensure she is in good general health. The patient does not have any history of cardiovascular disease (that she is aware of) and does not use any tobacco products nor does she drink any alcoholic beverages. The patient vitals were all within normal limits. Patient’s medical history does not display any need for pre-medication nor is a medical clearance required for the patient to continue with her dental treatment plan.
2. Dental History: (past dental disease, response to treatment, attitudes, dental I.Q., chief complaint, present oral hygiene habits, effect on dental hygiene diagnosis and/or care)
Patient’s chief complaint for visit is for a “cleaning.” Patient feels “ok” about the appearance of her teeth/smile due to heavy staining from drinking a cup of coffee every morning. Her last dental visit was January 2015 for a restoration for caries and also a cleaning was involved. When asked about that dental office, the patient was unsure of the DDS name or the name of the office. The patient is unaware of any past dental diseases due to infrequent dental visits. Patient checked “yes” to having many cavities at dental checkups. She also stated that her teeth are sensitive to cold, which can signify exposed dentin and is a sign of periodontitis. The patient is experiencing sensitivity due to the recession that has taken place, which is the result of bone loss. When asked why she doesn’t attend routine dental recall appointments, patient explains that her regular dentist use to be Dr. Jerry L. Burd DDS and after her periodontal treatment at his office about 4 years ago that she did not feel the need to go back after a few recall appointments. The patient also does not have any dental insurance, which can also be another reason for the infrequent routine dental exams. Infrequent dental visits correspond with overdue professional dental cleanings that result in plaque and calculus accumulation. The patient explained that the last dental visit was in Houston and that was only for the restoration to be filled. The patient stated that she recently received bitewing x-rays at the last dental visit in January 2015. She does not remember taking a panoramic x-ray. She remembers taking a full set of 20 pictures, which is an FMX at her initial appointment at Dr. Burd’s office about 4 years ago. Minimum restorative fillings have been accomplished in the patient’s mouth, as well. Patient will be informed of the importance of maintenance recalls and how keeping up with her oral hygiene through routine cleaning along with her personal hygiene. The patient should be aware of the LIT recall program, and she should be advised to return every 3 months. Patient’s attitude to receiving a dental cleaning was eager, however her learning level at the initial appointment was unaware. Patient’s dental I.Q. is poor along with her dental baseline oral hygiene habits and she is also unaware of her periodontal disease. Patient uses a soft bristle toothbrush, and brushes two times a day with occasional bleeding on gums. Bleeding is a noticeable sign that infection is taking place. Bleeding is directly related to plaque (bacteria) accumulation that can result in periodontal disease, decalcification, caries, and calculus formation. Rinsing, fluoride and other home care aids are not involved for the patient currently. Patient says she flosses sometimes after eating. Not flossing allows the plaque to calcify subgingival and the bacteria is constantly attaching to the hardened plaque known as calculus. All of these oral hygiene habits are contributing factors that have slowly progressed the patient’s periodontal condition from gingivitis to a chronic, moderate form of periodontitis, or bone loss (Periodontal Case Type 3). The progression of inflamed gingival tissue with red, blunted and/or rolled margins and papilla are characteristics of gum disease. However, if the inflamed area of bacteria from the plaque covering the tooth is not adequately removed this will progress into the other stage of periodontal disease, termed periodontitis. Periodontitis is actual bone loss, which holds the tooth secure in the mouth. Progression of this disease could lead to more destruction in the future if not treated immediately causing mobility of the teeth and eventually loss of the tooth altogether.
3. Oral Examination: (lesions noted, facial form, habits and awareness, consultation)
During the extra oral examination, all that was noted was the patient’s generalized ephelides, which are flat lesions with the etiology of sun exposure.
During the intraoral examination, it was noted that the patient has a slight torus palatinus, bilateral mandibular tori, and bilateral exostosis, which are all developmental. The patient also had linea alba on the left side and the etiology is from cheek biting.
During the occlusal examination, the patient’s right molar and canine were both Class I occlusion, the patient’s left molar is Class III, and the left canine is Class I. The patient has an overbite of 1mm (WNL), an overjet of 2mm (WNL), and has no midline shift.
The patient does not have any open bites or cross bites.
4. Periodontal Examination: (color, contour, texture, consistency, etc.)
a. Case Classification: 4 Periodontal Case Type: 3
b. Gingival Description:
The patient’s periodontal assessment reads that infection is taking place within the gingival tissues. The patient’s plaque accumulation has caused an inflammatory response on the gingival tissues. To prevent further progression the patient should begin excellent home care methods (brushing, flossing, rinsing) to help reduce the bacterial load in his mouth, and prevent more gingival tissue disturbances and halt disease progression.
App't 1:
Architecture: Generalized scalloped architecture
Color: Generalized redness
Consistency: Generalized edematous/spongy consistency
Margins: Generalized rolled margins
Papillae: Blunted in the mandibular anterior teeth lingually and bucally
Suppuration: None
Surface Texture: Generalized smooth and shiny (including attached)
App't 2:
Architecture: Generalized scalloped architecture
Color: Generalized redness
Consistency: Generalized edematous/spongy consistency
Margins: Generalized rolled margins
Papillae: Blunted in the mandibular anterior teeth lingually and bucally
Suppuration: None
Surface Texture: Generalized smooth and shiny (including attached)
App't 3:
Architecture: Generalized scalloped architecture
Color: Localized redness anterior mand. lingual
Consistency: Generalized edematous/spongy consistency
Margins: Generalized rolled margins
Papillae: Blunted in the mandibular anterior teeth lingually and bucally
Suppuration: None
Surface Texture: Generalized smooth and shiny (including attached)
App't 4:
Architecture: Generalized scalloped architecture
Color: Localized redness anterior mand. lingual
Consistency: Generalized edematous/spongy consistency
Margins: Generalized rolled margins
Papillae: Blunted in the mandibular anterior teeth lingually and bucally
Suppuration: None
Surface Texture: Smooth and Stippled
App't 5:
Architecture: Generalized scalloped architecture
Color: Localized redness anterior mand. lingual
Consistency: Generalized edematous/spongy consistency
Margins: Generalized rolled margins
Papillae: Blunted in the mandibular anterior teeth lingually and bucally
Suppuration: None
Surface Texture: Smooth and Stippled
App't 6:
Architecture: Generalized scalloped architecture
Color: Localized redness anterior mand. lingual
Consistency: Localized edematous/spongy consistency mandibular molars
Margins: Generalized rolled margins
Papillae: Blunted in the mandibular anterior teeth lingually and bucally
Suppuration: None
Surface Texture: Smooth and Stippled
c. Plaque Index: App’t 1: 2.0/Fair 2: 2.0/Fair 3: 2.0/Fair 4:1.0/Good 5: .6/Good
6: .5/Good
d.Gingival Index: Initial: 1.04/Fair Final: 1.16/Good
e. Bleeding Index: App’t 1: 3% 2:3% 3:1.1% 4:1% 5:0% 6:0%
f. Evaluation of Indices:
1. Initial: The evaluations of the following indices are signs that play as contributing factors to the patient’s prognosis of periodontal case type III, chronic, moderate periodontitis. The patient has moderate generalize plaque with large amounts of accumulation taking place in the maxillary posterior facial and lingual area, as well as, the interproximal areas of the posterior teeth. The patient’s plaque accumulation is directly related to her gingival inflammation and bleeding. The indices are rated higher than normal because of all of the bacteria that is taking place in the mouth. If the patient continues to allow plaque accumulation then continuation of bone loss could possibly take place. The patient’s gingival index is 1.8 which is considered fair.
2. Final: The patient has slight generalized plaque.
-The patient’s plaque accumulation is directly related to the slight inflammation and redness continuing to take place in the mandibular molar area. The bleeding score has improved which is a result from the proper home care taken place with the patient. The patient’s indices scores are rated good (better than initial appointment). With the patient’s proper homecare and eagerness to get back to a healthy state, I believe she in improving better that expected.
g. Periodontal Chart: (Record Baseline and First Re-evaluation data)
1. Baseline: Patient has generalized pocket depths ranging from 3-8 mm in the posterior area of both maxillary and mandibular teeth, facial and lingual, with deeper 5 mm pocket depth readings on the mesial and distal in the posterior areas posterior teeth.
The pocket depth along with clinical attachment level measured by probe has indicated several areas of unhealthy pocket depths and/or loss of tissue attachment that are contributing factors to patient’s moderate form of periodontitis. With 3-8 mm pocket depth measurements in the posterior area of maxillary and mandibular teeth, this indicates an early sign of an unhealthy pocket depth that the patient needs to be educated and informed about to halt the progression of receding pocket depths, and in the patient’s circumstance a disease known as periodontitis. The areas with the worse clinical attachment loss would be in the molar region of the maxillary left and the molar region of the mandibular on both left and right. With the attachment loss ranging from 4-5mm, the patient needs to be referred back to her periodontist after treatment. Through adequate brushing and flossing, the patient can help her tissues regain attachment to the teeth, especially in areas where a 4-8 mm pocket depth was recorded on the mesial and distal areas of the maxillary left and mandibular right teeth. The patient has recession on #3, #11, #12, #13, #19, #20, #28, and #30. Also, with tooth #32 being mesially impacted towards #31, and a defective restoration being found on the DO of #31, these are both contributing factors to the patient’s periodontal disease state because the defective restoration can now harbor bacteria and begin attacking the tooth, which in turn affects the sulcus where the gums start to recede leading up to the attack of bone loss in the specific area where visible loss of bone is evident on the radiographs. The patient has class I furcation on tooth #3, and class I furcation on #19 and #30. With the furcation involvement, the periodontal infection invades the area between and around the roots, resulting in a loss of attachment and los of alveolar bone between the roots of the tooth. The patient has no mobility, suppuration, or sensitivity.
2.Firstevaluation: The patients periodontal charting did show to change in the 7mm pocket areas that reduced to 5-6mm. The patient continues to have pocket depths between 4mm and 6mm pockets in the mandibular third molar region. The patient continues to have 4mm pockets taking place in the mandibular anterior region. The patient continues to have generalized 1mm of attachment loss with 2mm of attachment loss in the mandibular third molar region. This is directly related to the horizontal bone loss that already took place in the mandibular anterior region on the patient’s radiographs. The patient has no mobility, suppuration, or sensitivity.
5. Dental Examination: (caries, attrition, midline position, mal-relation of groups of teeth, occlusion, abfractions)
- Mid-line shift: none
- Right molar/canine occlusion: I/I
- Left molar/canine classification occlusion: III/I
- Overbite: 1 mm/WNL
- Overjet: 2 mm/WNL
- No open or cross bite
- Between clinical and radiographic findings, carious lesions have been detected on mesial occlusal of #32 and occlusal #14. As frequent exposures of tooth surface to acid occurs, demineralization occurs, and the caries process is initiated. A carious lesion begins to develop at the enamel as a white spot also known as an incipient lesion. If not properly taken care of with adequate oral hygiene care of brushing and flossing it will begin to eat away at the tooth causing more loss of tooth structure, and as a result complete tooth loss. As the bacteria from the carious lesion mature, it becomes more pathogenic playing a contributing factor to the patient’s periodontal condition of mild bone loss.
- Attrition on #6, #7, #8, #9, #10, #11, #22, #23, #24, #25, #26, and #27 from clenching.
- Occlusal-lingual tooth color filling on # 3, incisal mesial lingual tooth color restoration on #8 and #9, occlusal tooth color restoration on #20, #21, and #31.
- Abfraction on #12, #13, #14, #20, and #21
- Patient does not have any mal-relation groups of teeth.
- The patient does have a few areas of watch such as #12, #16, #17, #21, #28, #29, and #30. These areas should be monitored and better taking care of to prevent to progression of the incipient carious lesions.
6. Treatment Plan: (Include assessment of patient needs and education plan)
App't 1:
- Review medical/dental history, pre-rinse, FMX to evaluate bone loss and caries detection, head and neck extraoral exam, intraoral exam, periodontal assessment, dental charting with x-rays, full periodontal charting, complete risk assessment, acquire gingival index, acquire plaque and bleeding score
- Learning level: unaware; patient displayed poor plaque control, which were pointed out to the patient on the facial, buccal, and lingual surfaces, as well as interproximal of posterior teeth. Patient was not aware of severity of her bone loss. Flossing interproximal was also explained to patient in order to thoroughly remove the remaining plaque where her toothbrush cannot reach.
App’t 2:
- Review medical/dental history, pre-rinse, acquire plaque and bleeding score, assess gingival condition, finish Periodontal Assessment, finish Periodontal Charting
- Learning level: The patient is becoming more aware of her disease and is becoming involved and interested in treatment and to halting the progression of her disease. She is asking more questions about the treatment and is much more interested in regular dental care visits.
App't 3:
- Review medical/dental history, pre-rinse, acquire plaque and bleeding score
- Patient Education Session I: Plaque/brushing
- I will discuss both long and short-term goals created for the patient and explain to her how these correlate with the positive findings from the intraoral exam, periodontal assessment, radiographs and dental charting in order to improve her oral hygiene health. I will make sure to ask the patient if she thinks the long and short-term goals are attainable and go on to explain that better oral hygiene techniques from brushing to flossing will be recommended and demonstrated throughout future patient education sessions based upon her current oral hygiene needs.
- Discuss first long-term goal
- Patient will maintain plaque score of 0.8 or lower at each appointment.
- Discuss short-term goals
- Patient will learn how to brush in circular method while angle is towards the gingiva (gum), and able to demonstrate by next patient education session.
- Patient will understand what plaque is and be able to describe and define by next patient education session.
- Patient will brush her teeth every morning and night for 2 minutes.
- Discuss second long-term goal
- Patient will halt further bone loss and progression of her disease by effective plaque removal
- Discuss short-term goals
- Patient will describe how plaque contributes to periodontal disease and be able to define gingivitis and periodontitis by the next patient education session.
- Patient will learn how to wrap floss around fingers and demonstrate appropriate C-shape on typodont and on herself.
- Patient will floss 2-3 times a week after meals.
- Discuss third long-term goal
- Patient will have restorative treatment for cavities by the end of this year.
- Discuss short-term goals
- Patient will refer carious lesions to DDS (Show areas on radiographs where restorative work needs to be accomplished; #32 OM, #14 OL)
- Patient will be educated on caries and the process and be able to define by the end of treatment.
- Patient will understand what fluoride and sealants do to help aid against caries.
- Patient will make DDS appointment to have the cavities filled
- Next, I will ask questions to see what patient already knows; ‘Can you tell me what plaque is and what it can cause?’
- Explain what plaque is and how it affects the oral cavity
- After discussing plaque, the patient’s plaque score will be explained along with the purpose of the disclosing solution that was previously painted on her teeth. The different colors of the disclosing solution will be explained to the patient as old plaque stains light pink and new plaque stains dark pink. By painting the disclosing solution on the patient’s teeth after brushing, this allows us to see what areas were missed when brushing and as a result, where she needs to brush more effectively.
- Teach Skill (Brushing): Due to several areas that were missed along the gum line when plaque score was obtained, I will demonstrate the Bass Method technique on the typodont with a key focus on explaining the importance of angling her tooth brush 45 degrees towards the gum line massaging her gums in order to effectively remove and dislodge the remaining plaque that sits along the gum line and within the sulcus of her tooth. I will also show the patient how to vertically angle the tooth brush when brushing on her mandibular lingual anterior teeth due to the fact that most of the patient’s calculus and plaque buildup is in this area. Patient will then practice on the typodont angling the bristles towards the gums while doing a circular motion along with brushing her lingual anterior teeth with a vertical up and down motion until she feels comfortable with the new technique to demonstrate it on herself at the sink where the patient will be reminded of the importance tongue brushing. The tongue has a large amount of bacteria from plaque. If this is left on the tongue, bad breath can occur. Modifications will be made if needed at this time.
- Next, I will give the patient a brief idea about the next session: periodontitis and flossing. Questions will be asked to the patient to check for learning such as ‘Tell me what you remember about plaque? Why did I teach you the Bass Method technique? Do you remember what plaque can cause?’ Lastly, I will explain that this is a partnership in improving her oral health with the new brushing technique I have recommended. I am committed to teaching her and cleaning her teeth. However, it will also take time and great effort on her behalf to implement the new techniques and oral hygiene instructions at home to see the improvements.
- Topical/Local anesthesia, Ultrasonic scale quadrant I, Fine scale
App't 4:
- Review medical/dental history, Acquire plaque and bleeding score, pre-rinse
- Patient Education Session II: Periodontal Disease/Flossing
- Discuss first long-term goal
- Patient will maintain plaque score of 0.8 or lower at each appointment.
- Discuss short-term goals
- Patient will learn how to brush in circular method while angle is towards the gingiva (gum), and able to demonstrate by next patient education session.
- Patient will understand what plaque is and be able to describe and define by next patient education session.
- Patient will brush her teeth every morning and night for 2 minutes.
- Discuss second long-term goal
- Patient will halt further bone loss and progression of her disease by effective plaque removal
- Discuss short-term goals
- Patient will describe how plaque contributes to periodontal disease and be able to define gingivitis and periodontitis by the next patient education session.
- Patient will learn how to wrap floss around fingers and demonstrate appropriate C-shape on typodont and on herself.
- Patient will floss 2-3 times a week after meals.
- Discuss third long-term goal
- Patient will have restorative treatment for cavities by the end of this year.
- Discuss short-term goals
- Patient will refer carious lesions to DDS (Show areas on radiographs where restorative work needs to be accomplished; #32 OM, #14 OL)
- Patient will be educated on caries and the process and be able to define by the end of treatment.
- Patient will understand what fluoride and sealants do to help aid against caries.
- Patient will make DDS appointment to have the cavities filled
- Discuss previous session over plaque and brushing and ask to see if the patient has any problems and/or questions about her new brushing technique
- Praise patient for the short-term goals she has met
- Allow patient to demonstrate previous skill taught: Bass Method
- Patient Education Session II: Periodontitis/flossing
- Ask questions to see what the patient already knows; ‘Can you tell me what disease periodontitis is? Are you aware you have periodontitis?’
- Next explain the importance of removing interproximal plaque by flossing where a toothbrush cannot easily reach such as under the gum line and between the teeth; this can also reduce her plaque score
- Teaching Skill (flossing): Demonstrate proper flossing technique on typodont; curve the floss into a “C” shape around tooth, stopping when resistance is felt. Floss up and down several times against tooth making sure to use a clean section of floss as he moves from tooth to tooth; also avoid snapping the floss between teeth
- Allow patient to apply flossing method on typodont and once he feels comfortable have patient demonstrate on herself while looking in the mirror; modifications will be made at this time if needed
- Disclose and allow patient to evaluate how well she removed interproximal plaque by pointing out areas she missed and how to pay better attention next time when flossing
- Ask questions to check for learning; ‘Tell me what you remember about periodontitis? Why is it important to remove interproximal plaque?’
- Encourage patient to floss 2-3 times a week, and give patient a brief idea about next session: caries process and prevention
- Establish partnership in improving oral health; however, she will need to do the home care work in order for the treatment to be successful! (Teamwork)!
- Local anesthesia, Ultrasonic scale quadrant 2, Periodontal chart, Fine scale
App't 5:
- Review medical/dental history, acquire plaque and bleeding score, assess gingival condition
- Patient Education Session III: Caries/Fluoride
- Discuss first long-term goal
- Patient will maintain plaque score of 0.8 or lower at each appointment.
- Discuss short-term goals
- Patient will learn how to brush in circular method while angle is towards the gingiva (gum), and able to demonstrate by next patient education session.
- Patient will understand what plaque is and be able to describe and define by next patient education session.
- Patient will brush her teeth every morning and night for 2 minutes.
- Discuss second long-term goal
- Patient will halt further bone loss and progression of her disease by effective plaque removal
- Discuss short-term goals
- Patient will describe how plaque contributes to periodontal disease and be able to define gingivitis and periodontitis by the next patient education session.
- Patient will learn how to wrap floss around fingers and demonstrate appropriate C-shape on typodont and on herself.
- Patient will floss 2-3 times a week after meals.
- Discuss third long-term goal
- Patient will have restorative treatment for cavities by the end of this year.
- Discuss short-term goals
- Patient will refer carious lesions to DDS (Show areas on radiographs where restorative work needs to be accomplished; #32 OM, #14 OL)
- Patient will be educated on caries and the process and be able to define by the end of treatment.
- Patient will understand what fluoride and sealants do to help aid against caries.
- Patient will make DDS appointment to have the cavities filled
- Discuss previous session over periodontitis and flossing and ask to see if the patient has any problems and/or questions about flossing
- Praise patient for the short-term goals she has met
- Allow patient to demonstrate previous skill taught: C-Shape flossing technique
- Patient Education: Caries Process and Prevention, Fluoride and Sealants
- Ask questions to see what patient already knows; ‘Do you know what causes a cavity?’
- Explain caries process: a cavity is formed when bacteria contained in the plaque convert sugar and carbohydrates into acids, next, these acids dissolve minerals in the tooth surface where it begins to erode the enamel creating a pit in the tooth structure
- Show patient radiographs of carious lesions
- Remind patient that damage can occur anywhere the tooth is expose to plaque and acid, which is why brushing and flossing is important. This helps reduce bacteria load, therefore decreasing the disease that can occur in the mouth
- Explain preventive measures against cavities such as fluoride and sealants
- Fluoride is a topical anti-caries agent that help strengthen the teeth by remineralization of demineralized areas of tooth surface
- Sealants also help protect tooth from caries by sealing off any irregularities on the tooth surface that has likelihood for harbor bacteria
- Review skills of brushing, flossing, and tongue brushing
- Ask questions to check for learning; ‘Tell me what 3 factors create a cavity? What are preventive measures to prevent cavities?’
- Encourage patient to brush 2 times a day, floss 2-3 times weekly and brush tongue properly
- Establish partnership in improving oral health; however, he needs to continue doing her homecare- we are a team!
- Thank patient for their time and effort!
- Local anesthesia, Ultrasonic/scale quadrant 3, Periodontal chart, Fine scale
App't 6:
Review medical/dental history, Acquire plaque and bleeding score, Assess gingival condition, Obtain final gingival index, Chair-side Patient Education: Importance of regular dental care visits, Explain to the patient the importance of regular dental exams and how keeping up with her oral hygiene can help halt the progression of her disease, Local anesthesia, Ultrasonic scale quadrant 4, Final periodontal charting, Fine scale. Referral to periodontitis is needed due to moderate periodontitis.
App't 7:
- Review medical/dental history, Acquire plaque and bleeding score, Assess gingival condition, Obtain final gingival index, Chair-side Patient Education: Restorative treatment, referrals, check-ups, and prophy, Make sure to schedule D.D.S. appoint for both restorative treatment on indicated teeth as well as referral of maxillary and mandibular molars to oral surgeon, Review skills of brushing, flossing, and caries prevention, Final periodontal charting, Post calculus, Arestin: explain the significant pocket re-attachment of antibiotic placed within pocket, Plaque Free, Fluoride, Referral of caries on #32, #14, and 3 month recall interval
7. Radiographic Findings: (crown root ratio, root form, condition of interproximal bony crests, thickened lamina dura, calculus, and root resorption)
- Patient has generalized moderate horizontal bone loss in the posterior of the maxillary and mandibular region which is the evidence of past disease. This is mostly related to periodontal disease and its progression.
- The patient also has moderate horizontal bone loss in the anterior mandibular area.
- There is no visible calculus on the radiographs. This is related to periodontal disease and the current state of the periodontal patient.
- The patient has generalized loss of crestal lamina dura which is associated with periodontal disease.
- The patient’s mandibular tori are visible in the anterior mandibular radiographs. This is not related to periodontal disease but should be monitor for enlargement.
- Patient has visible furcation involvement on #2, #14, and #30, which is from the breaking down of bone surrounding the roots of the teeth. This is associated with periodontal disease and can progress to mobility and in loss of the tooth if not closely taken care of.
- Tooth #3 and #32 are extruded which also is a factor in her disease.
8. Journal Notes: (Record in detail the treatment provided, oral hygiene education, patient response, complications, improvements, diet recommendations, learning level, short and long term goals, expectations, etc.) The progress notes should be written by appointment date.
Appt 1 (October 5, 2015): Treatment: Reviewed medical and dental history, prerinse, intraoral and extra oral exams, periodontal assessment, dental charting, plaque score, bleeding score, FMX survey due to the clinical evidence of periodontitis. Education: Discussed plaque and sulcular brushing method. Patient Response: The patient seemed to be interested in the topic, and eager to get treatment. Complications: The patient has a smaller mouth than normal and tends to close easily. I used a mouth prop in order to continue proper treatment. Learning Level: unaware. Long-term goal was to reduce the plaque score and short-term goals is learning how to brush correctly and understand the importance of the disturbance of the plaque in the oral cavity. An important diet recommendation given to the patient was to avoid heavy coffee drinking to prevent stains and to lower sugar to prevent the cavity rate. The patient’s learning level is unaware at this appointment.
Appt 2 (October 12, 2015): Treatment: Reviewed medical and dental history, prerinse, finished complete periodontal charting, started inform consent and risk assessment. I took the plaque score and bleeding score and finished periodontal assessment. Education: The importance of flossing and how it can halt the progression of her disease. I also explained to the patient that we will be having patient education sessions at every appointment and will clean a specific area in order to understand the prevention measures along with treatment. The patience response is that she likes using floss picks only. I explained that we would further explain the importance in the correct methods in floss usage and her periodontal health in a further detailed patient education session. Reviewed all LTGs and STGs with the patient. The patient’s learning is aware at this appointment.
Appt 3 (October 19, 2015): Treatment: Reviewed medical and dental history, prerinse, took plaque score and bleeding score. Start the first scaling and ultrasonic in the mandibular right. Education: The formal first patient education session was taught to the patience about the importance of plaque destruction and the definition. Reviewed all LTGs and STGs with the patient. Explained to the patient to correct sulcular 45-degree angle brushing to remove plaque properly and efficiently. I also educated the patient with tongue brushing and to brush 2x/day for 2 minutes. The patient seemed very confident in reaching these goals due to that fact that she does brush that often per day, the only thing that we modified was her old method of brushing to the correct method. The patient was again recommended to avoid heavy drinking of coffee and teas. The learning level is at self interest by this appointment.
Appt 4 (October 30, 2015): Treatment: Update and review the medical and dental history, prerinse, take plaque score and bleeding score, and start scaling the second quadrant of the mandibular left. Education: The second patient education session was taught to the patient about definition of periodontitis and how it affects the oral cavity. Reviewed all LTGs and STGs with the patient. Flossing is essential to remove plaque in between teeth to prevent further bone loss. I taught patient the “C-method” of flossing. She was definitely having difficulty using the floss correctly toward that back areas of the mouth. With that I recommended her to use the floss picks in the back areas but to use the regular floss in the front and over time with practice she will be able to better her technique. The patient showed improvement in brushing due to the lowered plaque score recorded and attained all the STGs from the first patient education session. The patient’s learning level is at action at this appointment.
Appt 5 (November 2, 2015): Treatment: Review and update medical and dental history, prerinse, take plaque score and bleeding score, and start scaling/ultrasonic the third quadrant of the maxillary left. Education: I taught the patient about the caries process, the definition, and the prevention measures. Fluoride can play a huge role in her prevention and can be found in specific mouth rinses and dentifrices. Reviewed all LTGs and STGs with the patient. It was emphasized about the importance of routine care to halt the progression of her disease. The patients response to the fact she had cavities was very shocking to her due to the fact that she recently had restorative treatment and with my response again that it ties into the importance of regular dental care to be able to detect these cavities and to reduce any bacterial counts all go with routine care. The patient was able to attain the STGs in result of reduce bleeding score and the patient successfully demonstrated the correct flossing technique chair side. The patient’s learning level is at action at this appointment.
Appt 6 (November 9, 2015): Treatment: Review and update medical and dental history, prerinse, take plaque score and bleeding score, and start scaling maxillary right (last quadrant), flossed and plaque free. Education: Explained that the next appointment we will be apply arestin which is an antibiotic to the deep pockets in the mouth. Reviewed proper brushing and flossing and emphasized the importance in home care to successfully complete the treatment and to maintain health in the mouth. The patient did complete a LTG and decided to get in contact with a previous DDS to restore her cavities. The learning level at this appointment is involved and action.
Appt 7 (November 23, 2015): : Treatment: Reviewed medical and dental history, prerinse, plaque score, bleeding score, gingival index, sealants (#12, #4, #5, #13), full post perio charting, hand scaling full mouth to check for residual calculus, Fluoride gel, placed Arestin. Patient education: discussed STG and LTG, discussed Arestin and its importance as an antimicrobial in illuminating bacteria in pockets, re-demonstrated brushing on the typodont and has patient re-demonstrated at sink just to be sure of the correct technique and methods. Patient response: My patient was very interested in the Arestin she asked several questions regarding this topic. I also reminded the patient to avoid flossing in area for 7-10 days and gave her an informative packet regarded Arestin information. LL-Action. Complications: The only complication was probably applying the Arestin, but after the first one, it became easier to apply. The patient stated that she will return to Dr. Burd’s office for routine care which is a great goal she has reached.
9. Prognosis: (Based on attitude, age, number of teeth, systemic background, malocclusion, tooth morphology, periodontal examination, recare availability)
Overall Prognosis: Good
-I rate my patient a good prognosis because my patient does not have any systemic factors and patient is very cooperative and eager during overall treatment to go back to the healthiest state possible. The patient shows commitment and involvement. This is resulting in the reduction of plaque in the patient’s mouth every appointment. My patient has generalized 4 to 6 mm pockets that did improve by her post evaluation appointment which was a great improvement. My patient is 46 years old and has remaining functional teeth. My patient admits to cutting down on heavy coffee sugary drinks and limited herself to just one a day versus the multiple cups she had before. I rate my patient a good prognosis instead of fair or poor, because she had made multiple efforts to improve her oral health, including making an appointment to go back to her periodontitis. The patient is self employed which means she is able to make recare appointments easily with the clinic or her periodontitis. This shows me as her health profession that she is more than serious about her health and the only thing that was preventing her was the proper education. The patient’s malocclusion is in a good state where there aren’t areas of heavy plaque retention.
-Prognosis for individual teeth- #31L and #30L (fair) have 6-7 mm pockets allowing a possible environment for gram – bacteria to accumulate and breakdown the periodontium resulting in loss of attachment and further complications but during the post evaluation that was a reduction in pocket depth. #14 and #32 (fair) has occlusal carious lesions. These carious lesions could provide an environment for gram – bacteria to accumulate but that patient has already stated she will be getting these restored so after they do I believe they will be in a good state. I rate all of the above teeth as fair due to the fact that they will be corrected soon by a dental care professional.
10. Supportive Therapy: Suggestions to patient regarding re-evaluation, referral, and recall schedule.
I explained to my patients the results of the re-evaluation appointment. I explained that with her proper home care methods that there is an improvement of gingival and periodontal pockets. I praise the patient on how great she has been doing and encourage her to continue the home care even after treatment to maintain a healthy oral cavity. I recommended the patient to use floss aids in order to get into the molar areas since she was having difficulty using regular floss. Referrals that my patient had are for carious lesions on #14 and #32. With my constant reminders, my patient has decided to return to her periodontitis for regular treatment. As for her re-evaluation, I put her down for a three-month recall-February 2016.
11. Assessment of Changes: (including plaque control, bleeding tendency, gingival health, probing depths)
Plaque control- Overall by reviewing the plaque indices the patient shows improvement of plaque control, which shows that she is successful in completing proper home care.
Bleeding tendency- Overall by reviewing the bleeding indices my patient did show improvement, which can conclude from proper flossing techniques being used.
Gingival Health- overall my patient’s gingival health improved tremendously. My patient gingival index had decreased by .59. The reduction is most likely related to heavier plaque accumulation in the beginning of treatment. The redness and inflammation were slight.
Probing depths- My patients probing depths did change by her post evaluation appointment in a few areas. The patient continued to show generalized 4-6mm pockets in the third molar region, but with some of the heavier 8mm and 7mm pockets were reduced to 5-6mm. I believe this is the result of proper oral hygiene and with other areas may need attention from a periodontitis.
Statement- Overall, my patient has improved greatly in areas of plaque and gingival health. If my patient continues the proper home care and starts to get back into her routine dental care, the full halt of her disease can be reached which is the main goal in our treatment.
12. Patient Attitudes and Cooperation:
My patient’s attitude was as positive and attentive. At each appointment, my patient was prompt and came in with an eager and motivating attitude. Once I started explaining to her the severity of her disease, she was more than willing to get treatment and was eager to be at the clinic. She has a few difficulties understanding specific processes such as her periodontal disease and the caries process, but with constant patient education and chair side education; she had further understood the information. Overall, I feel blessed to have such a patient person in my chair because she was very calm and attentive. Throughout her treatment, her bleeding score and plaque scores were reducing which showed she was very effective in her homecare.
13. Personal Evaluation/Reaction to Experience:
For me this was a great learning experience. I must admit that this was a difficult challenge at first, but completely worth it in the end. I have learned so much from this periodontal case and the periodontology class. During this project I found myself contributing more time and effort to the gingival tissues and how to determine healthy vs. unhealthy. I had a saying that I told my patient at every appointment, “A Healthy Mouth Never Bleeds.” That statement led her to be more motivated in home care and preventing any type of bleeding regardless if it was during brushing or flossing. It was amazing to see the gingival tissues transform week-to-week and knowing what was taking place. This was the first patient I have ever had the opportunity to recognize a change in tissue and understand what was occurring. I was also very pleased at how involved my patient was in restoring her oral health to the healthiest state possible. I find it fascinating how disease progression takes place in the mouth. It was very beneficial for me to have this assignment because not only did it further educate me with periodontitis but also it truly helped me through lecture because all of the information coincides with our treatment plans with our patient. The specific subjects I learn in class help me further educate my patient in every way possible.
Patient Education
- First long-term goal
- Patient will maintain plaque score of 0.8 or lower at each appointment. COMPLETE
- Short-term goals
- Patient will learn how to brush in circular method while angle is towards the gingiva (gum), and able to demonstrate by next patient education session. COMPLETE
- Patient will understand what plaque is and be able to describe and define by next patient education session. COMPLETE
- Patient will brush her teeth every morning and night for 2 minutes. COMPLETE
- Second long-term goal
- Patient will halt further bone loss and progression of her disease by effective plaque removal. PROGRESS
- Short-term goals
- Patient will describe how plaque contributes to periodontal disease and be able to define gingivitis and periodontitis by the next patient education session. COMPLETE
- Patient will learn how to wrap floss around fingers and demonstrate appropriate C-shape on typodont and on herself. COMPLETE/PROGRESS
- Patient will floss 2-3 times a week after meals. COMPLETE
- Third long-term goal
- Patient will have restorative treatment for cavities by the end of this year. PROGRESS
- Short-term goals
- Patient will refer carious lesions to DDS (Show areas on radiographs where restorative work needs to be accomplished; #32 OM, #14 OL). PROGRESS
- Patient will be educated on caries and the process and be able to define by the end of treatment. COMPLETE
- Patient will understand what fluoride and sealants do to help aid against caries. COMPLETE
- Patient will make DDS appointment to have the cavities filled COMPLETE