Treatment Plan Assignment #2

COD Patient

Dental Hygiene II

Larissa Henecke
I. Assessment

A. Patient Interview
1. Has some sensitivity to cold on teeth
2. Broke tooth #13
a) Patient states tooth is sensitive
b) Patient is scheduled for RCT and crown prep
B. Medical/Dental History
1. Hypertension
a) Controlled with Atenolol (Wynn, pg 151)
(1) No oral considerations
2. Generalized anxiety
a) Not medicated
3. Allergies
a) Penicillin
b) Sulfa Drugs
4. Last visit to dentist was 8 years ago
5. Went to dentist regularly as a child
6. Patient had previous orthodontic treatment and frenectomy
C. Social History
1. Age 31
2. Caucasian
3. Female
4. Drinks socially
5. Previous smoker
D. Vital Signs
1. BP 132/90
E. Intra-oral/Extra-oral Examination
1. Fordyce granules on lips
2. 1 x 1 mm hematoma on left buccal mucosa
a) Patient states she bit her cheek
3. No frena attachment on maxilla
a) Patient states she had frenectomy as child
4. Varicosities under tongue
5. Broken tooth #13
6. Generalized decalcification along gum line of posterior teeth
a) Likely from orthodontics
7. Gingiva Description: generalized healthy, pink, pointed, firm & resilient,
stippled
 8. Periodontal Examination: bleeding absent, generalized <3mm probing
depths, generalized 1-2mm recession on posterior teeth
9. Plaque score 29%
F. Radiographs
1. Broken tooth #13
2. Overhanging margin on restoration → mesial #12
3. Slight generalized bone loss in posterior

II. DH Diagnosis

A. Level of Health
1. Patient is in good health
2. Hypertension controlled with medication
3. Generalized Anxiety
B. Diagnosis
1. Periodontal Case Type: Generalized Slight
2. Class C Calculus

III. Plan

A. Consultations Necessary
1. Endodontic
a) RCT for #13
2. Prosthodontics
a) Crown #13
3. Restorative
a) Remove overhanging margin #12
B. Treatment Goals
1. Improve OHI
a) Establish routine
2. Reduction of sensitivity
3. Place patient on regular dental recall
C. Addressing Phases of Treatment
1. Phase I therapy
a) OHI instruction
b) Varnish fluoride
c) Ultrasonic and hand scaling
d) Polishing and flossing
e) Have overhanging restoration on #12 corrected
2. Phase II surgical
 a) Endodontic treatment of #13
3. Phase III restorative
a) Crown #13
4. Phase IV maintenance
a) 6 month recall appointment
b) Establishing OHI routine

IV. Implementation

Patient presented for dental cleaning and stated she has not had a cleaning or been to the

dentist in 8 years. Intra and Extra oral examination of the patient were within normal limits.

Upon initial assessment patient had moderate calculus and visible bridge of supra calculus on the

lingual surfaces of lower anterior teeth. Begin by demonstrating proper brushing (BASS) and

flossing (C-wrap) and encourage patient to establish a routine, brush 2x daily and floss 1x daily.

Demonstrate use of auxiliary flossing aids for areas of food impaction (floss picks & Flossmate

floss holder) and dispense Sensodyne toothpaste for sensitivity. Do initial debridement of

calculus with ultrasonic (Wilkins, pg. 624). Use anesthetic if patient has any discomfort (Curran,

pg. 83-84). Follow-up with hand scaling, polishing and flossing. Send patient home with soft

toothbrush, glide floss, Sensodyne toothpaste, Flossmate floss holder, and soft picks. Discuss

with patient, for any post-op discomfort, they may take what they regularly take for a headache.

Schedule patient for 6 month recall appointment and make sure patient is aware of upcoming

appointments for treatment of #13. Prognosis for patient is good if she follows recommended

treatment and homecare instructions.

V. Evaluation

A. How Care is Evaluated

1. Follow up charting
a) Probing depths
 b) Recession measurements
2. Radiographs
a) Evaluate images
(1) Bone loss
(2) Calculus
3. Patient OH Behavior Changes
a) Plaque score
b) Gingival health/condition
c) Sensitivity level
d) Flossing routine/use of auxiliary flossing aids
 References

Curran, A. E., Myers S. L. (2015). General and oral pathology. Philadelphia, PA: F. A.

Davis Company.

Wilkins, E. M. (2013). Clinical practice of the dental hygienist. Philadelphia, PA:

Lippincott Williams & Wilkins

Wynn, R. L., Meiller, T. F., & Crossley H. L. (2016). Drug information handbook for dentistry

22nd edition. Hudson, Ohio: Lexicomp, Inc.