Dental Hygiene III

Special Needs Treatment Plan

Rachel Oakes
I. Assessment (Preliminary Phase)

A. Patient Interview: Patient needs a dental cleaning that will be covered by Title IX

Insurance.

B. Medical/Dental History: Patient is a 51-year-old male. He has mild-to-moderate

intellectual disability, complex partial seizure disorder, a history of depression

and has visual impairment that requires glasses. Patient has had a bacterial

infection that required him to be hospitalized for treatment within the last 5 years.

Patient uses a C-PAP machine at night for sleep apnea. Patient does receive bi-

yearly dental exams with the last exam being on 7/11/18. Patients last dental

hygiene appointment was also on 7/11/18. Patient is allergic to Keppra. Patients

caretaker states that he, or another caretaker, brushes the patient’s teeth twice a

day and flossing is very difficult for them.

Medications include:

1.) Chlorhexidine Gluconate 0.12%, once daily; Pharmacologic

Category: Antibiotic, Oral Rinse; Use: antibacterial dental rinse;
Effects on Dental Treatment: increased tartar on teeth, altered taste
perception, staining on oral surfaces, and oral irritation.
2.) Depakote ER, 500 mg daily; Pharmacologic Category:
Anticonvulsant; Use: therapy in the treatment of patients with
complex partial seizure disorders; Effects on Dental Treatment:
taste perversion, periodontal abscess; Effects on bleeding:
associated with dose-related thrombocytopenia.
3.) Propranolol ER, 60 mg daily; Pharmacologic Category:
Antiangial Agent, Antiarrhythmic Agent, Antihypertensive, Non-
Selective Beta-Adrenergic Blocker; Use: Management of
hypertension, aggressive behavior, TOF hypercyantoic spells;
Local Anesthetic/Vasoconstrictor Precautions: Use epinephrine
 with caution; Effects on Dental Treatment: may enhance pressor
response to epinephrine, NSAID use may reduce hypotensive
effect.
4.) Clonazepam, 1 mg as needed; Pharmacologic Category:
Benzodiazepine; Use: treatment of seizure disorders, treatment of
panic disorders; Dental Use: burning mouth sydrome; Effects on
Dental Treatment: xerostomia, changes in salivation, gum soreness
and coated tongue.
5.) Levothyroxine, 25 mcg daily; Pharmacologic Category: Thyroid
product; Use: Replacement/supplemental therapy in
hypothyroidism.
6.) Lamotrigine, 150 mg daily; Pharmacologic Category:
Anticonvulsant; Use: Adjunctive therapy in the treatment of
seizures including generalized tonic-clonic and partial seizures;
Effects on Dental Treatment: xerostomia; Effects on Bleeding:
Thrombocytopenia and anemia have been reported in less than 1%
of patients.
7.) Abilify, 5 mg daily; Pharmacologic Category: Antipsychotic
Agent; Use: Treatment of bipolar disorder, irritability associated
with autistic disorder, major depressive disorder and
schizophrenia; Effects on Dental Treatment: Extrapyramidal
symptoms, xerostomia and salivary changes.
8.) Escitalopram, 10 mg daily; Pharmacologic Category:
Antidepressant, Selective Seratonin Reuptake Inhibitor; Use:
Treatment of major depressive disorder, generalized anxiety
disorders; Local Anesthetic/Vasoconstrictor Precautions: Use
caution in patients that have had drug-induced torsade de pointes
with administering vasoconstrictors and consult with their
physician.
9.) Multivitamin, unknown dose once daily; Pharmacologic
Category: Dietary Supplement.
 Patient has a short attention span but can sit still for a short (one hour maximum)

appointment. He is able to communicate and understand the basics of treatment

modifications so use of an ultrasonic scaler would be beneficial. Due to patients

very strong lower lip and a very active tongue thrust, an assistant will be needed

during the appointment to help retract them for speed and efficiency. Being direct

and telling the patient exactly what I expect of him is important and will help with

keeping control of the appointment. Due to his seizure condition, I need schedule

his appointments in the morning and confirm he has taken his medications; being

aware of what steps are necessary in case he has a seizure episode is also very

important.

C. Social History: Pt. has a past history of tobacco use but does not use it currently.

Patient does not drink or use recreational drugs. Patient can interact socially but

cannot recall any medical or dental history on his own and has regular social

outbursts.

D. Vital Signs: Patients’ blood pressure is 119/82 and his pulse was 63 BPM.

E. Extra-Oral Examination: within normal limits; Intra-Oral Examination: Patient

presents with generalized chapped lips, bilateral tori on mandible, tongue has

generalized coating, third molars are all present; Color of the Gingiva:

Generalized red, hard palate presents pale in color (from C-PAP use); Contour of

Interdental Papilla: Generalized bulbous; Marginal Gingiva: Generalized slightly

rolled; Consistency of Gingiva: Generalized spongy and edematous; Texture of

Gingiva: Generalized non-stippled; Bleeding on Probing: Generalized

spontaneous bleeding; Moderate generalized calculus build-up especially on the

 mandibular anterior region; Generalized light-to-moderate plaque accumulation;

Calculus Class B; Dental Exam: No decay detected but watch the buccal pits of

#32, #17 because incipient caries white spot lesions are present. Due to these

areas of incipient caries, the dentist wants silver diamine fluoride (SDF) applied.

F. Periodontal Examination: Patient has generalized <3mm readings with localized

areas of readings of 4-5 mm. Pockets depths of 5 mm were found on the distal of

#17, #31, #32; while pocket depths of 4 mm were found on distal of #18, #19 and

on mesial of #17, #31, #32. Periodontal Case Type: Generalized Gingivitis.

G. Oral Changes Based on Special Needs: Patient is unable to perform oral hygiene

instruction on his own and relies on caretakers in a group home to perform it for

him so flossing and brushing are a challenge. This contributes to his gingival

inflammation and POB. He has his third molars; they have deeper probing depths,

incipient caries and his tongue thrust makes them hard to clean. He has overactive

salivary glands despite xerostomia being a side effect of some medications.

H. Radiographs: Patient had 4 vertical bite wings made on 7/11/18, shows no

significant bone loss.

II. DH diagnosis

A. Level of Health: At this point in time, the patient is in fair physical health and bad

oral health with a low level of understanding how to fix it. I believe that the

patient does not have the ability to understand and provide themselves adequate

home care upon proper instruction and with the possible use of any aids if

necessary. He may be able to use a toothbrush on his own on some days but
 generally, it would be best to provide oral hygiene instruction to his care takers

for a better overall outcome.

B. Diagnosis: Generalized Gingivitis; 4-5 mm depths are due to inflammation as

there is no significant bone loss on radiographs.

III. Plan

A. Consultations Necessary: General Dentist, Oral Surgeon consultation for possible

third molar extraction.

B. Treatment goals for our patient:

1. Arrest progression of gingivitis

2. Remove calculus and plaque

3. Educate patient and care takers on oral disease and self-care techniques

C. Phases of treatment: One appointment treatment plan with six month recalls.

IV. Implementation (Phase I therapy)

Review health/dental history, medications, allergies and take patients’ blood

pressure. Assess extra-oral health and intra-oral hard and soft tissue conditions. Begin

probing while charting all findings. Discuss OHI with patient and patients care taker

including incorporating using a floss pick into his routine a few times a week and

reminding them to brush his teeth at night. Introduce and demonstrate the Bass technique

and C-shaped flossing technique. Discuss patients diet and discuss carbohydrates and

sugars role in caries risk.

Begin scaling using area the Cavitron ultra sonic scaler to remove interproximal

and lower mandibular anterior calculus. Follow this by using specific Gracey curettes to

remove the remaining supra and subgingival calculus. Following this procedure, check
 effectiveness with an 11/12 Explorer. Once calculus is effectively removed, begin

polishing with a medium prophy paste due to staining and then floss patients full mouth.

Place cotton rolls on the buccal surfaces of #17, #32 and dry the area thoroughly. Mix

and place SDF. After, change gloves and apply a NaF fluoride varnish.

Post-op instructions for NaF fluoride varnish include not eating or drinking

anything hot for 30 minutes and that in 4-6 hours his teeth can be brushed but since the

appointment is in the morning, his caretaker is safest to just wait to brush his teeth before

bed that night. Also, to tell the patient and his care taker about potential discomfort after

the appointment and to avoid spicy food. Send patient home with a soft bristled

toothbrush, toothpaste, floss pick and check to make sure he doesn’t need a

Chlorhexidine Gluconate rinse refill prescription.

B. Phase IV Maintenance: Put patient on a six-month recall in Special Care Clinic.

V. Evaluation (Outcomes evaluation of phase I)

A. Care given will be evaluated by decreased bleeding, decrease in plaque and

calculus, and a decrease in gingival inflammation. While patient is unable to care

properly for his own oral health, as a provider my main goal is to maintain his

current state of no bone loss with regular cleanings and emphasizing oral hygiene

instructions to both him and his care taker.

B. Follow-up Charting: Re-probing patient; documenting areas of bleeding.

C. Radiographs: Patient shows no additional bone loss; new bitewings every year

based on dentists’ recommendations.

D. Patient OHI behavior changes: Re-evaluate plaque amount in oral cavity.

 References

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

Including oral medicine for medically-compromised patients & specific oral conditions (22nd

ed.). Hudson, OH: Lexicomp.

Wilkins, E. M. (2017). Clinical practice of the dental hygienist (12th ed.). Philadelphia: Wolters

Kluwer.

Myers, S. L., & Curran, A. E. (2015). General and oral pathology for dental hygiene practice.

Philadelphia, PA: F.A. Davis Company.