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Dental Hygiene II

Treatment Plan #2
Rachel Oakes
I. Assessment (Preliminary Phase)

A. Patient Interview: “I haven’t been to the dentist in 5 years and need my teeth

cleaned.”

B. Medical/Dental History: Patient is a 31-year-old female. She has

Gastroesophageal reflux disease, suffers from depression and has seasonal

allergies. Patient has had her gallbladder removed and gastric sleeve surgery

within the past year. Patients blood pressure is 130/85. Patient does not receive

yearly dental exams but recently had a full dental exam on 2/14/18. Patients last

dental hygiene appointment was 5 years months ago. Patient is allergic to

Penicillin products. Patient states that she brushes her teeth once a day in the

morning and flosses irregularly.

Medications include:

1.) Bupropion, 300 mg daily; Pharmacologic Category:


Antidepressant, Dopamine-Reuptake Inhibitor; Use: treatment of
major depressive disorder/seasonal effective disorder; Effects on
Dental Treatment: abnormal taste, significant xerostomia; Effects
on bleeding: thrombocytopenia in <1%.
2.) Lexapro, 10 mg daily; Pharmacologic Category: Antidepressant,
Selective Serotonin Reuptake Inhibitor; Use: treatment of major
depressive disorder/generalized anxiety disorder; Effects on Dental
Treatment: xerostomia, toothaches; Effects on bleeding: may
impair platelet aggregation.
3.) Omeprazole, 40 mg daily; Pharmacologic Category: Proton Pump
Inhibitor, Substituted Benzimidazole; Use: treatment of
heartburn/GERD; Effects on Dental Treatment: taste perversion,
dry mouth, esophageal candidiasis, and mucosal atrophy.
4.) Ortho Tri-Cyclen, dosage unknown; Pharmacologic Category:
Contraceptive; Use: treatment of Acne vulgaris and for the
prevention of pregnancy; Effects on Dental Treatment: When
prescribing antibiotics, patient must be warned to use additional
methods of birth control.
5.) OTC antihistamines, as needed; Pharmacologic Category:
Histamine H1 Antagonist; Use: relief of allergic reactions caused
by histamine release; Dental Use: relief of nasal mucosal
congestion and relief of oral erosions including aphthous
stomatitis; Effects on Dental Treatment: xerostomia, dry mucous
membranes.
6.) Calcium Citrate, 1000 mg daily; Pharmacologic Category:
calcium salt; Use: Dietary supplement.
7.) Vitamin D, 2000 IUs daily; Pharmacologic Category: Dietary
Supplement; Use: plays a role in bone and calcium homeostasis.
8.) Prenatal Vitamins, unknown dose; Pharmacologic Category:
Dietary Supplement; Use: to help cover any nutritional gaps in a
mother's diet.
9.) Biotin, unknown dose; Pharmacologic Category: Dietary
Supplement.
C. Social History: Pt. occasionally smokes cigarettes and drinks a regular soda

beverage every day.

D. Vital Signs: Blood pressure 130/85.

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

granules present bilaterally on lips, one 1x1mm small, circular, red cheek bite on

the buccal mucosa between #15, #18, maxillary frena is red, oral pharynx is

generalized red, Bilateral tori on mandible, almond-shaped tori on the hard palate,

tongue has generalized coating, tongue is fissured and has a scar on the midline
from a previous tongue piercing, third molars #1, #16, #17 are partially erupted;

Color of the Gingiva: Generalized pink, localized red on mandibular arch;

Contour of Interdental Papilla: Generalized pointed/normal, #5, #6, #10, #11 are

flat; Marginal Gingiva: Generalized knife-edged, rolled in the mandibular

posterior; Consistency of Gingiva: Generalized firm and resilient, spongy and

edematous on the mandibular anterior; Texture of Gingiva: Localized stippled on

anterior, localized non-stippled on posterior. Bleeding on Probing: Localized

spontaneous bleeding. Calculus Class B.

F. Periodontal Examination: Patient has generalized <3mm readings, mesial lingual

of #30 is 5mm; Periodontal Case Type: Localized Gingivitis.

G. Radiograph: Patient had OP200 made on 4/25/18 and 4 bitewings made on

2/14/2018.

II. DH diagnosis

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

oral health. I believe that the patient has the ability to understand and provide

themselves adequate home care upon proper instruction and with the possible use

of any aids if necessary.

B. Diagnosis: Localized Gingivitis.

III. Plan

A. Consultations Necessary: 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 on oral disease and self-care techniques

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

IV. Implementation (Phase I therapy)

A. 1st appointment:

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 and calculus detection while charting all findings. Disclose patient and record the

new plaque score. Discuss OHI with patient including incorporating flossing into her

routine and brushing her teeth at night. Introduce and demonstrate the Bass technique and

C-shaped flossing technique. Discuss switching to a diet soda beverage instead of full

flavor; inform patient to drink sodas all at once and not to sip on it all day.

Begin scaling using area specific Gracey curettes to remove supra and subgingival

calculus. Following this procedure, check effectiveness with an 11/12 Explorer. Once

calculus is effectively removed, begin polishing with a fine prophy paste due to minimal

staining and floss patients full mouth. Post-op instructions include to tell the patient about

potential discomfort after appointment. For pain, they may use an NSAID of their choice

as needed. Also advise to rinse mouth with salt-water and to avoid spicy food. Send

patient home with a Biotene sample to help with medication induced xerostomia.

B. Phase IV Maintenance: Put patient on a six-month recall.

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.


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

C. Radiographs: Patient shows no additional bone loss.

D. Patient OHI behavior changes: Preform and re-evaluate plaque indices.

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.

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