Andrea Schubert

Treatment Planning #3
July 13th, 2014
1. Assessment
a. This patient is an 80 year old Caucasian male.
b. Patient returned for a recall visit. His last hygiene cleaning was 6
months ago as well as his last dental exam. He flosses daily with
his floss aid and brushes twice a day. He has a great medical
history and has remained healthy. No allergies are noted. He is
currently taking the following medications; Diltiazem, Januvia,
Nortriptyline, Promethazine.
c. This patient is hard of hearing as noted in his chart; he does not
wear a hearing aid. When treating the patient it is important to
talk slow and allow them to see you as you speak in order for
proper understanding.
d. Patient has no history of alcohol or drug abuse.
e. Blood Pressure 126/74
f. Extra oral examination: TMJ has grinding on left side of jaw.
Intraoral examination: Linea alba, mandibular tori, coating on
tongue and generalized attrition on anterior teeth. Tonsils are
absent. He has 28 teeth. Gingiva are generalized pink,
generalized flat/normal, generalized rolled, generalized firm and
resilient and generalized stippled. There was no bleeding on
probing. Occlusion is Class I right and Class II left with an end to
end bite.
g. Probing depths are generalized less than 3mm, generalized
recession of 2mm.
h. No oral changes will occur due to the patients special need
i. Radiographs were not taken. Past radiographs do not show areas
of concern.
2. This patients main concern is generalized moderate.
3. Plan
a. None
b. Treatment goals: Maintain low plaque score and continue daily
oral health habits
c. Therapy Phase would involve removal of biofilm and calculus
with ultrasonic and hand instruments. The surgical phase would
not be necessary with his current oral health conditions. The
restorative phase would involve any final restorations or
prostheses, but these are not necessary for this patient.

d. Our role is to provide the best care during the appointment

through implementing the ultrasonic, hand scaling, OHI,
polishing, and flossing. The patients role is to maintain OHI by
continuing use of floss aid and interproximal brush. The patient
should schedule a 6 month recall to keep oral hygiene in check.
4. Implementation
a. Sickle, 1/2 & 11/12 & 13/14 Graceys
b. Ultrasonic FM, Hand scaled FM, polish with medium prophy
paste, floss
c. Interproximal Brush, Floss Aid
d. No anesthetic is necessary
e. None given
5. Evaluation
a. Evaluated oral hygiene and noted patient maintains good
routine. Probing depths maintained from previous visit. Overall
oral health patient is being well maintained and extra
precautions at this time are not necessary.
b. None needed
c. Patient is very respectful and listened carefully to directions and
followed through with them. He asked questions when there was
something which he did not understand.

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.