Cassie Nauholz

Treatment Planning #2
I. Assessment
I. Patient interview: Patient is a 31-year old white Caucasian male.
He has come to the dentist for a cleaning and has not been for
almost 7 years.
II. Medical/dental history:
Medical: The patient is not currently taking any medications.
He has no recent hospitalizations or illnesses. He has no
allergies.
Dental: The patient has not been to the dentist in a few years
and thinks his last cleaning could have been as long as 7
years ago.
III. Social history: The patient is a social drinker and chews about
can of tobacco a day. His diet consists of pop, energy drinks, chips,
candy, and whatever his girlfriend makes him for dinner, which is
generally fairly healthy.
IV. Vital signs: BP: 117/72
V. Intra-oral/extra-oral exam:
E/O: The patient has an extra oral exam that is within normal
limits.
I/O: Patient appears to have hyperkeratosis on the right labial
mucosa. The patient appears to have a white coating on the
dorsal surface of the tongue. Patients tooth #18 is fractured
patient states he broke his tooth while chewing on a pen cap.
Gingival description: generalized redness, generalized pointed
interdental papilla, recession on the right mandibular
anteriors, generalized slight inflammation, slight bleeding
present when exploring and probing. Patient demonstrated a
plaque score of 22%.
VI. Periodontal examination: Localized periodontal readings less
than 4 mm. Generalized bleeding present when probing.
VII. Radiographs: Patient has horizontal bitewing radiographs
available and a pano. Radiographs show eruption and impaction of
third molars also causing damage to the second molars because of
the direction of growth. Caries are also visible on the patients
radiographs.
II. DH Diagnosis

a) Level of Health: The patient seems to be in overall good health.

With better oral hygiene practice at home and some lifestyle
changes such as quitting tobacco chew and improving the diet, the
patient can improve his overall health.
b) Diagnosis: Generalized gingivitis based on swollen red gums that
bleed easily upon probing.
III. Plan
Consultations necessary: Nutrition counseling to better diet to avoid
decay. Discuss the affects chewing tobacco has on the oral cavity and
why quitting would benefit the patient in the long run. OHI to help
patient understand the importance of brushing and flossing every day.
No specialized dentist consultation needed at this time.

Treatment goals: Since the patient appears to have generalized

gingivitis there are a few things the patient can do to reverse this
problem and return to a healthy mouth.
Reduce plaque and bacteria in the oral cavity by developing a
good at home oral hygiene routine.
Develop a flossing habit by flossing once a day.
Quit chewing.
Develop a better brushing technique to get rid of plaque in
mouth focus on posterior teeth.

Phases of treatment:
Preliminary phase:
Assesment data collection: I will collect health and
dental data from the patient to decide what kind of
treatment is needed for the patient.
Phase I therapy:
Dental biofilm control: Control of biofilm by polishing
and flossing.
Introduction of preventive measures: Explaining the
affects the patients diet has on his oral cavity and how the
use of tobacco chew is affecting his mouth now and what
can happen in the future as long as use is continued.
Calculus removal: Will remove calculus from patients
teeth by scaling the entire mouth.
Outcomes evaluation of phase I:
Probing depths: Compare probing depths from first
appointment and second appointment to see if there are
any changes in the numbers probed.

Clinical
signs
of
inflammation:
Compare
the
inflammation of the gingiva from the first appointment to
the second appointment to see if the inflammation has
decreased.
Dental biofilm control: By disclosing the patient at the
second appointment, I will compare the plaque score to the
first appointment and see if there is a decrease in the
amount of plaque present in the patients mouth.
Patients participation: By comparing the gingiva,
bleeding when probing, and the plaque score, this will
show me if the patients home care has gotten better.

Evaluation of overall outcomes:

Periodontal response to restorations/implants: Since
the patient needs some restorations due to some caries
that are present, I will check the response of the
surrounding hard and soft tissues where the patient had
the restorations done.
Phase IV maintenance:
Appointments for continuing care and supervision:
The patient is scheduled for a 6-month recall where we will
re-evaluate the patients oral health and home care
techniques
Refining biofilm control techniques: Will give good OHI
on how to brush and floss the correct way by making
modifications to the patients current techniques.

IV. Implementation
I will talk with the patient about the affects his diet has on the
oral cavity. I will explain how consuming energy drinks and pop will
have a negative effect on his teeth and will contribute to his caries risk.
Drinking water throughout the day is a good suggestion for the patient
to replace the energy drinks and pop being consumed. By helping the
patient to improve his diet, I will give him some ideas of foods to eat
that are not cariogenic and will be better for his oral health and overall
health.
The use of chewing tobacco is also something that is having a
negative impact on his oral health. I will explain to him the risks of
chewing now and in the long run. By quitting chewing, the patient will
find the healing process of gingivitis to be more efficient and effective.
This will also prevent bone loss in the future and will help the patient
avoid periodontal disease.
OHI is also important to help the patient understand the
importance of brushing and flossing every day. Teaching the patient

the proper way to brush and floss and having the patient demonstrate
each of these is important in bettering the health of the patient. The
patient showed a lot of plaque buildup on the posterior teeth, which is
an area to educate the patient to focus on.
The patient should also be educated on the importance of a
professional cleaning once every six months. The patient does not
make regular visits to the dental office, but by explaining the benefits
it can have on the oral cavity, it may encourage him to visit the dentist
more regularly.
I will hand scale 4 quadrants, polish the full mouth, and floss the
full mouth to remove any plaque, calculus and staining. I will also apply
a fluoride tray with 2% sodium fluoride for 4 minutes at the end of the
appointment. This will contribute to better protection of the teeth from
caries and help with remineralization. I will also instruct the patient to
not eat or drink anything for 30 minutes after the fluoride tray is
applied. The patient will be given a soft toothbrush, fluoride
toothpaste, and floss to take home. The patient will be put on a 6month recall since no signs of periodontal disease are evident at this
time.
V. Evaluation
a) How we will evaluate care: When the patient returns for his 6month recall appointment, we will check for a change in his gingiva
while doing an intra-oral exam and evaluate his gingival health. We
will also look for an improved plaque score and see if the patients
bleeding of gingiva has improved since the last visit. If the patient
does not show improvement in oral health, I may suggest a
Chlorhexidine rinse. I will check the labial mucosa where the patient
is now showing hyperkeratosis and see if there is a change in the
tissue. If the patient has quit chewing or moved the tobacco to
another place in the mouth, the tissue should be healed and back to
normal. If it has not healed, the patient should have the tissue
biopsied.
b) Follow-up charting: During the next visit, we will probe again to
compare the numbers charted from this visit. We will want to pay
close attention to any measurements that have gotten deeper than
the last visit. We will also note a change in the bleeding of the
gingiva when probing compared to the first visit.
c) Radiographs: Since the patient does not seem to have a high
caries risk, radiographs are not necessary for at least another year
unless the patient has pain or there is a concern below the gumline.

d) Patient OH behavior changes: I will discuss any changes in the

diet with the patient. I will ask him if he has been making better
choices when it comes to snacks and if he has been drinking more
water and less energy drinks and pop. I will check the status of the
patients tobacco use and ask if he has decreased his use or
stopped using chewing tobacco all together. We will also discuss
how his oral hygiene care is going at home and if he has developed
a better routine.