1.

Assessment

 Patient interview:
o Patient is a 52 year old Caucasian female that is here for her 6-month
appointment.
o Patient’s chief complaint:
 “I just started having sensitivity on my two front teeth where my
restorations are”.
 Dental history:
o Patient regularly visits the dentist 2x a year
o Patient brushes 2x a day with an electric tooth brush and flosses daily
o Previous X-rays taken in 2014
o Patient grinds her teeth
 Medical history:
o Patient has a history of high blood pressure
o Current medications
 Hydrochlorothiazide
 Category- Antihypertensive, diuretic
 Use- Management of mild-moderate hypertension
 Dental Effect: Take caution when moving patient, slow
movements in chair
 Social history:
o General diet consists of cariostatic foods and water
 Vital signs:
o BP- 138/70
 Intra-oral examination:
o Lingual tissue is torn on #4
o Oral Pharynx- tonsils absent
o Maxilla- incisive papilla and torus
o Mandible- bilateral torus on #’s 21-23 and 27-29
o Gingiva:
 Color- generalized pink
  Interdental Papilla- generalized pointed and localized anterior
mandibular tissue clefting
 Recession- 5,11,12,21,22 and 23
 Rolled- 6,18,21,27,28 and 29
 Consistency- generalized firm and resilient
 Texture- generalized stippled
 Bleeding: generalized bleeding
o Teeth:
 Total No.- 32
 Attrition- localized on mandibular and maxillary anteriors
 Calculus Detection:
 Sub- 3
 Supra- 3
o Plaque score index:
 12%
o Previous areas of concern per Dentist’s findings:
 Recurrent caries on #’s 6,24,25 and 27
 Extra oral examination
o Three moles on the left side of next by the cervical chain
o Right TMJ shift, asymptomatic
 Periodontal examination
o Generalized probing depths <3 mm and 4 mm localized probing depths of
6mm on the posterior molars
o Generalized bleeding
 Radiographs:
o Radiographs of periapicals of 8 and 9 and 4 BWS. Vertical bone loss on
the BWS.

2. DH Diagnosis

 Level of Health
o Generalized good health, with the exception of high blood pressure which
is maintained by medication
 o Patient has an overall healthy diet
o Patient bruxes and is causing bone loss and attrition to her teeth
 Diagnosis
o Perio Case Type- generalized slight
o Calculus Class- B

3. Plan

 Risk Factors To Consider For Treatment Plan

o Behavioral- None
o Iatrogenic- Sensitivity to cleaning on #’s 8 and 9 and areas of recession.
Mandibular torus.
o Hormonal- Patient is at menopausal age and is at risk for gingival
inflammation due to hormonal fluctuations
 Dental considerations: Bleeding during prophylaxis
 Educate patient about gingivitis and the importance of
brushing the gums.
o Nutritional- None
 Level of Oral Health Knowledge
o Patient brushes twice daily with electric tooth brush and flosses daily.
Patient brushes aggressively and flosses incorrectly.
 Role of Patient
o Brushing softer and flossing in a “C” shape position to protect gingiva
o Follows homecare instructions for wearing mouth guard at night
o Shows up to all future appointments
 Consultations Necessary
o See dentist for an exam and treatment of caries
o Endo consultation for sensitivity with #’s 8 and 9
o Consultation for possible qualification for bite guard
o Operative consultation for possible restoration of 8 and 9
 Treatment Goals
o Address sensitivity to #’s 8 and 9
o Complete removal of calculus and plaque.
 o Patient understands and follows oral health instructions given
o Instruct patient on importance of eliminating bruxing habits
o Instruct patient on importance of brushing softly to protect her gums
o Instruct importance of maintaining bone level
o Teach patient how to floss correctly to protect gingiva
o Improve tissue health.
 Prognosis
o Fair to good- if patient follows oral hygiene instructions and treatment
plan
 Phases of Treatment
o Preliminary phase
 Assessment of data
 Emergency care (pain/ biopsy)
 Sensitivity in #’s 8 and 9
 4 BW’S and peri of 8 and 9
o Phase I therapy
 Dental biofilm control
 Super floss for restorations being fused together on #’s 8
and 9
 Sensitivity toothpaste for recession
 Introduction of additional preventive measures
 Mouth guard for bruxing
 Calculus removal
o Outcome evaluation of phase I
 Probing depths
 Clinical signs of inflammation
 Dental biofilm control
 Patients participation
o Phase II Surgical
o Phase III restorative
 Consultation for possible restoration of 8 and 9
 o Evaluation of overall outcomes
 Gingival response to plaque control
o Phase IV maintenance
 Appointments for continuing care and supervision
 Refining biofilm control techniques

4.Implementation

 Our patient discussed that she just started having sensitivity in on #’s 8 and 9. The
main concern of our appointment is to address her dental pain, educate our patient
to understand the importance of good dental care and to give our patient a fresh
start. To start I gave my patient oral hygiene instructions which insisted of
discussing brushing her gums and teeth lightly with a soft toothbrush head to
avoid causing more recession and stop the gums from bleeding. We also
discussed that she is flossing too aggressively and is injuring her gums. I showed
her how to floss in a “C” shape to avoid hitting her gums. I gave her Superfloss to
help her floss under her bridge and advised her to start using Sensodyne for her
sensitivity and recession. When performing the extra oral exam we found the
TMJ shifts to the right upon closing. When asking the patient she claims that she
grinds her teeth when she is stressed and at night. When performing the intra oral
exam we discovered localized attrition on the max and mandibular anteriors. To
determine bone loss and I took 4 BWS and a periapical of 8 and 9. The
radiographs showed generalized vertical bone loss on the posteriors. We
discussed that her constant grinding may contribute to her bone loss and the
sensitivity to her two front teeth. I advised her to start wearing a mouth guard at
night to protect her teeth. We discussed that she is categorized as generalized
slight and is losing bone loss due to constant grinding. I emphasized that if she
keeps this up she could potentially lose her teeth and she needs to make sure she
maintains her bone level. She may qualify to get a bite guard so Endo will consult
with her about that as well as discussing her sensitivity. She also will need a
consultation with Operative to possibly restore her restorations. During her Dr.
exam recurrent caries were discovered and the patient will need treatment. I hand
scaled and finished full mouth with gracey 11/12, gracey 13/14, gracey ½ and the
H5/33 sickle. Then evaluated scaling effectiveness with 11/12 explorer. I then
polished full mouth with Next fine grit paste due to the low plaque score and
minimal stain. I then flossed full mouth and showed patient how to use a
Superfloss on #’s 8 and 9 due to the restorations being fused together. For the
fluoride treatment I administered NaF fluoride trays for two minutes. Upon
finishing I informed the patient to not eat or drink for 30 minutes after the fluoride
treatment. We put her on recall in 6 months and scheduled appointments for
cavity restorations, endo and operative consultations.
5. Evaluation
 Treatment plan has been modified to fit patients improved needs
o Patient is will be satisfied with the results she sees and won't have any
more dental sensitivity because she will listen to home care instructions
provided by dental hygienist and had Endo consultation
 Patient will maintain her oral health over time as long as she sees dentist regularly
 Patient is interested in maintaining bone level
 Treatment goal will be met because she:
o Will star wearing a night guard to protect her teeth from bruxing
o Will brush less aggressive
o Will maintain generalized slight perio case type
o Will repair the interdental papilla due to correct flossing form
 Follow up charting will show:
o Probing depths decreasing
o Restored cavities
o Decreased bleeding on probing
o Maintain generalized slight perio case type
 Radiographs
o CMs including 6 vertical BW’S at follow up appointment after
restorations have been completed and to monitor periodontal disease.
References
Wilkins, E. (2017). Clinical practice of the dental hygienist: twelfth
edition. Philadelphia, PA:
Wolters Kluwar,

Crossley, H., Miller, T., & Wynn, R. (2014). Drug information handbook for dentistry.
Hudson, OH: Lexicomp Publishing.