Andrea Schubert

Treatment Planning #2
April 24, 2014
1. Assessment
a. This patient is a 22 year old Caucasian male.
b. Patient returned for a recall visit. Noted sensitivity on tooth #8
when drinking and eating cold beverages. His last hygiene
cleaning was 6 months ago as well as his last dental exam. Prior
to college he was seeing the dentist regulary and took a couple
years off and wants to get back on track. He uses ACT fluoride
rinse as directed from his last hygiene appointment to streghten
his teeth. He flosses a couple times a week and brushes twice a
day. He has a great medical history and has remained healthy.
He had a Tonselecomy when he was 4 and his 3rd molars
removed when he was 20. As a child he had an allergic reaction
to Ceclor and Sulfa medication. He takes Singulair as needed
which could cause dry mouth but the patient hasnt had any
complications as of now.
c. Patient has no history of alcohol or drug abuse.
d. Blood Pressure 120/76
e. Extraoral examination: TMJ has a click on left Jaw. Intraoral
examination: Lips chapped and Fordyce granules. Linea alba on
the buccal mucosa. White coating on tongue. Tissue trauma on
teeth #3 and #14. Tonils are absent. He has 28 teeth with
generalized decalcification and remineralization. Gingiva are
generalized pink with localized red on maxillary anteriors,
generalized pointed/ normal, generalized knife-edged with
localized rolled on linguals, generalized firm and resilient and
localized spongy and edematous on maxillary canine to canine,
and generalized stippled. There was no bleeding on probing.
f. Probing depths are generalized less than 3mm with localized
4mm on DF #3, MF #14, #18, DL #19, MF #30, MF #31.
g. Radiographs showed risk of caries.
2. This patients main concern is generalized gingivitis.
3. Plan
a. None
b. Treatment goals: improve pocket depths and maintain lower
plaque score.
c. Therapy Phase would involve removal of biofilm and calculus
with hand instruments, tray fluoride treatment to hit
interproximal decay. The surgical phase would not be necessary

with his current conditions. The restorative phase would involve

any final restorations or prostheses, but this are not neceessary
d. Our role is to provide the best care during the appointment
through hand scaling, OHI, polishing, and fluoride trays. The
patients role is to improve OHI by creating a flossing habit with
posterior teeth. A floss aid was given to help with this. Using
previ-dent as prescribed by the Doctor to help keep caries under
control. Also throwing away old tooth brush when sick or
becomes no longer usable. An extra tooth brush was given to
help motivate this step. The patient should schedule a 6 month
recall where he is moving to and attend those appointments to
keep oral hygiene in check.
4. Implementation
a. Sickle, 1/2 & 11/12 & 13/14 Graceys
b. Hand scale, polish with fine prophy paste, floss, fluoride trays
c. Floss aid
d. No anesthetic is necessary
e. PreviDent
5. Evaluation
a. Evaluated the improvement of oral hygiene, probing depths
improved from previous visit, inflammation of gums improved
and were no longer red, plaque score had decressed, bleeding on
probing remained non existent, and calculus detection improved
from previous visit.
b. 4 bitewings given
c. Brushing and flossing habits improved, very respectful and
listened carefully to directions and followed through with them.

References:
Wilkins, Esther. (2013). The dental hygiene care plan. Clinical Practice of the
Dental Hygienist. (351-360).
Crossley, H.L, Meiller, T.F. & Wynn, R.L. (2013). Drug Information Handbook
for Dentistry.