Assessment:

Medical and Dental History:

 Brendon is currently under the care of his primary physician for nutritional counseling and
behavioral issues.

 He sees an endocrinologist for growth hormone treatment to increase his growth, decrease his
body fat, and improve his muscle tone.

 He is on a strict and well-balanced diet that includes healthy foods that are proportioned
throughout the day.

Medications:

 Somatropin injection- growth hormone

 Testosterone- sex hormone to help with the development of sex organs

 Clotrimazole- treatment of candidiasis

Blood Pressure: 118/78

Pulse: 100

Oral Inspection:

 Thick and sticky saliva

 Plaque Index- 84%

 Candidiasis is present on the palate

 Gingival color- generalized red

 Gingival consistency- smooth and shiny

 Gingival contour- generalized thickness and rolled

 Gingival shape- generalized bulbous and flaccid

 Position of gingival margin- generalized coronal to CEJ

 Carious lesions are clinically visible on every tooth

  Generalized severe attrition

 Generalized enamel hypoplasia

 Generalized moderate plaque build up

 No evident bone loss

 Based on the radiographs and clinical evaluations the patient is in mixed dentition state.

Primary Teeth Present- A, B, C, H, I, J, K, L, S, T

Permanent Teeth Present- 3, 7, 8, 9, 10, 14, 19, 22, 23, 24, 25, 26, 27, 30

Diagnosis:

 The xerostomia is caused by the patient’s systemic disease, medications, and his decreased
salivary flow. By increasing his water intake and recommending him xylitol mints, this may
produce an increased salivary flow thus decreasing his risk for caries.

 The candidiasis that is present on his palate is caused by the xerostomia and his condition. He is
currently prescribed Clotrimazole to treat the candidiasis.

 His gingival tissues appear red as a result of his decreased salivary flow, poor home care, and the
excessive plaque present throughout his dentition.

 The carious lesions that are present on every tooth are caused by the patient’s decreased
salivary flow and his frequent carbohydrate intake. Since he is currently seeing a physician
regarding nutrition the patient’s caries risk should decrease.

Planning

 Appointment 1: The medical and dental history was assessed. Intra/extra oral inspection was
completed. A plaque index was completed. A panoramic and four horizontal bitewings were
taken. Patient education was discussed and the Modified Stillman’s Method was recommended
and demonstrated to the patient and the guardian. The proper flossing technique was
demonstrated to both patient and guardian.

 Appointment 2: The medical and dental history was reassessed and intra/extra oral inspection
was performed. A plaque index was completed to see if the patient had improved with his home
care. Patient education consisted of evaluating the patient’s brushing and flossing techniques
and a reiteration of the proper technique was demonstrated with the guardian present. The use
 of fluoridated toothpaste was introduced and discussed. The patient was hand scaled and
selectively polished in all four quadrants. A five percent neutral sodium varnish was applied to
the entire dentition with post-operative instructions.

Implementation:

This is the phase where the dental hygiene services are performed. The special accommodation’s that
were implemented were shorter appointments because the patient presented to the clinic anxious.
Also, instead of a child sized cuff, an adult cuff was used when taking the blood pressure due to the
obesity of the patient. The ultrasonic scaler was not used due to the primary dentition that was still
present.

Evaluation:

Since Brendon had generalized plaque and carious lesions, it was recommended that he should have
three month recare appointments. At every appointment with Brendon, his home care should be
assessed to ensure that the proper technique for brushing and flossing is used to remove plaque on a
daily basis. Another recommendation is that fluoride should be given at every appointment. The
benefits of fluoride should be discussed with Brendon and his mother. The carious lesions present
should be discussed with Brendon and his mother and restorative procedures should be scheduled.