Treatment Planning Assignment #3

Laura Argello
July 23, 2013

1. Assessment a. Patient Interview i. Patient is a 56 year old Caucasian male. b. Medical/Dental History i. Has regular dental checkups ii. Last dental hygiene visit was on 3/2/12 iii. Has vagus nerve stimulation implanted on the left side of his heart that is stimulated when he passes a device over his heart when he feels a seizure aura iv. Hospitalized for seizure in 2005-brain trauma, craniotomy, projectile vomiting in 1975 v. Last simulated seizure was at the hospital on 2/11/12 vi. Last unmonitored seizure was a grand mal seizure in 2010 vii. Daily medications: Gabitril, could increase the risk of gingivitis, Keppra, lamictal, may cause xerostomia, trileptal, multivitamins, and omega 3 vitamins c. Patient has history of epileptic seizures d. Social History i. Patient tolerated treatment well, patient is a very peaceful person that loves to travel and stay active e. Vital Signs i. Blood Pressure: 108/70

f. Intra-Oral/Extra Oral Examination i. Extra Oral: WNL ii. Intra Oral: Irritation fibroma on left cheek, 4mm, circumscribed. Scar on left side of cheek and tongue, both from past seizures years ago. Plaque Score: 52% g. Periodontal Examination i. No bleeding ii. No recession iii. All <3 mm iv. Generalized slight B calc v. Perio pockets >4 on #3 h. Increased risk for gingivitis and xerostomia from medications i. Radiographs i. No bone loss, crown on #19 ii. 4 Vert BWS & Peri #2,3 on 3/2/12 iii. Peri #19 on 2/16/12 iv. 18 CMS on 6/9/11 v. 1 BW on 8/25/10 vi. 2BW on 7/28/09 vii. 4 BW on 5/20/08 2. Diagnosis a. Perio case type- generalized slight

3. Plan a. Consultations i. Had periodic exam with Dr. Morgan on 6/14/13 b. Treatment Goals i. Hand Scaled full mouth, polish full mouth, floss full mouth, educate patient on general OHI and schedule for a 6 month recall c. Phases of Treatment i. Review data-Make sure patient is medicated with his anti-seizure medication ii. Remove plaque, give OHI and remove calculus iii. Evaluate probing depths, perio signs, plaque removal, and patient participation and feedback iv. Schedule patient for 6 month recall appointment d. My Role as the Hygienist i. Obtain documentation of informed consent/ refusal from the patient. Present, discuss and document treatment plan with patient. Explain rationale, risk, benefits, anticipated outcomes, treatment alterations and prognosis. Give complete oral hygiene instruction. Complete plaque and calculus removal, complete prophylaxis and evaluate results.

e. Patient Role i. Document consent, come to the appointment on time, and pay for the appointment. Understand treatment plan and ask any questions he/she may have. f. Implementation i. The appointment will begin with a review of the treatment plan with the instructor and patient. Next, I will hand scale the entire mouth to remove and subgingival and supragingival calculus. After calculus removal, I will complete a full mouth prophylaxis with fine grit prophy paste and floss the entire mouth. I will discuss OHI with the patient and the importance of using a soft bristled tooth brush twice daily for two minutes using the BASS method and flossing daily with the c shape method. No anesthetics or new prescriptions were given. Patient declined fluoride, so no fluoride will be administered. I will end the appointment by evaluating completion of the treatment plan and set the patient up for 6 month recall appointment. g. Evaluation i. At the 6 month recall I will re-probe the entire mouth to check for any perio pockets and overall gingival health, I will apply disclosing solution on the teeth to check for an improved plaque score. Patient will be due for new bite wing radiographs. I will then discuss the effectiveness of his home regimen since his last visit.

References

Crossley, R.L., Meiller, T.F., & Wynn, R.L. (2011). Drug information handbook for dentistry. Ohio, Hudson: Lexicomp. Wilkins, E. (2013). Clinical practice of the dental hygienist. Philadelphia, PA: Wolters kluwer bussness. ADHA. (2008). Standards for clinical dental hygiene practice.