Assessment

a. Patient interview
i.
80 years old
ii.
White Caucasian
iii.
Female
iv.
Requests information and recommendations about dry
mouth products
b. Dental history
i.
Regular dental visits to COD
ii.
Brushes with electric Sonicare TB
iii.
Uses Prevident 5000+ at night
iv.
Flosses 5-7 times per week
v.
Previous extractions
vi.
Xerostomia
vii.
Bleeding gums
viii. Ingests fluoride from water and toothpaste
c. Medical History
i.
Allergies
a. Tessalon
b. Bactrim
c. Clotrim
d. Levaquin
e. Penicillin
i. Pt states she had testing done at Mayo Clinic and
is no longer allergic to penicillin
ii. Clindamycin for premed
iii. Updated health history
ii.
Systemic health
a. Thyroid disease
b. Irregular heartbeat
c. High blood pressure
d. High cholesterol
e. Arthritis
iii.
Artificial joints (requires premed by orthopedic surgeon)
a. Knee
b. Hip
iv.
Surgeries
a. Tonsillectomy
b. Gallbladder and calcium deposits removed
c. Cyst and ovary removed
d. Total R Knee replacement 2006
e. Total L Hip replacement 2008
f. Total hysterectomy
v.
Medications taken daily (Unless noted)
a. Prevident 5000+
b. Calcium 1000mg

3166

I.

c.
d.
e.
f.
g.
h.
i.
j.
k.
l.

d.

e.
f.

g.

h.

Multivitamin
Pravastatin 10 mg
Timolol Mal 10mg
Vitamin C 500mg
Diovan
Levothyroxine
Omega 3
Aspirin 86mg
Glucosamine
Clindamycin HCl (4x 150mg)
i. Taken as antibiotic premedication required from
orthopedic surgeon
Social history
a. Never smoked
b. Regularly consumes snacks- crackers, cheese, cookies,
cake
c. Lives in an assisted living facility with husband
d. COD patient for many years and extremely satisfied with
treatment received
Vital signs
a. BP- 140/78
Extra oral examination
a. Thyroid clicking when palpated
i. Pt states she gets thyroid levels checked every 6
months
Intra oral examination
a. Maxillary torus present
b. Tonsils absent
c. Xerostomia
d. Varicosities present on and around submandibular gland
e. Amalgam tattoo #28 L
f. Multiple localized smooth red macules where #14 should
be
i. UL edentulous ridge
ii. Present due to food trauma
Periodontal examination
a. Generalized pink gingiva
b. Generalized normal/pointed interdental papilla
i. Localized blunted papilla maxillary anteriors
c. Generalized firm and resilient consistency
d. Generalized stippled gingiva
e. Generalized spontaneous BOP
f. Exudate absent
g. Probing depths
i. Generalized 4mm or less
ii. Localized 5-6mm UR molars

II.

III.

i. Radiographs if available
a. Radiographic calculus absent
b. Horizontal bone loss present
DH Diagnosis (Problem Identification)
a. Level of health
i. Pt is in fair health
b. Diagnosis
i. Periodontal Disease
1. Generalized slight
2. Localized moderate
Plan
a. Consultations necessary
i. DDS active caries
1. 3L
2. 28B
3. 5DO
ii. DDS watch
1. 29L
b. Treatment goals
i. Maintain periodontal health
ii. Increase homecare
iii. Provide dry mouth products
1. Patient comfort
2. Caries prevention
c. Addresses phases of treatment
i. Preliminary phase
1. Assessment data collection
a. General health
i. Thyroid disease
ii. Irregular heartbeat
iii. High blood pressure
iv. Artificial joint replacements
v. Fair health
b. Medication effects
i. Increased/prolonged bleeding
ii. Xerostomia
iii. Taste perversion
iv. Orthostatic hypotension
v. Cough
vi. Muscle weakness
vii. Fluoride staining
c. Oral health behaviors
i. Meals prepared by assisted living facility
ii. Phase I therapy
1. Dental biofilm control

IV.

a. Educated patient on effects of plaque and its

relation to periodontal disease
2. Introduction of additional preventive measures
a. Fluoride
b. Saliva sure
c. Biotene
3. Calculus removal
a. Effective hand scaling in all 4 quadrants
iii. Outcomes evaluation of Phase I
1. Probing depths
a. Reduce or maintain probing depths
2. Clinical signs of inflammation
a. Reduce pseudo pockets in posterior teeth with
proper OHI
3. Dental biofilm control
a. Proper brushing and flossing methods applied
4. Patients participation
a. Patient is adamant about keeping her teeth as
long as possible and with proper OHI she will
succeed
iv. Evaluation of overall outcomes
1. Periodontal response to restorations/implants
a. Reduce pseudo pockets around posterior teeth
with restorations with proper OHI
v. Phase IV maintenance
1. Appointments for continuing care and supervision
a. 6 month DHYG recall
b. Proper care for active caries if they become an
issue for patient
2. Refining biofilm control techniques
a. Notice problem areas with disclosing solution
and reviewing proper OHI at each appointment
Implementation
a. Patient presents with chief complaint of xerostomia. She requests
products for alleviating dry mouth symptoms. Patient is currently
taking Calcium, Multivitamin, Pravastatin, Timolol Mal, Vitamin C,
Diovan, Levothyroxine, Omega 3, Aspirin, Glucosamine and
Prevident 5000+. She took Clindamycin HCl (4x150mg) for
premed an hour before appointment. Tessalon, Bactrim, Clotrim,
Levaquin, and Penicillin allergies. BP- 140/78. Extra oral- Thyroid
clicking when palpated. Pt. states she gets her thyroid levels
checked every 6 months. Intra oral- Maxillary torus present,
xerostomia, varicosities present on and around submandibular
gland, tonsils absent, amalgam tattoo 28L, multiple localized
smooth red macules where #14 should be. Pt states it hurts
when she eats something hard due to food trauma. Generalized

V.

pointed/normal interdental papilla, localized blunted papilla on

maxillary anteriors. Generalized probing depths 4mm or less.
Localized 5-6mm UR molars. Perio case type- Generalized slight,
localized moderate. No plaque score due to beginning scaling
while waiting for DDS exam. Hand scaled FM. Polished FM with
fine grit mint Enamel pro prophy paste. Flossed FM. No
anesthetic needed. Prescription given for Prevident 5000+.
Fluoride varnish applied due to severe xerostomia. Discussed
proper brushing and flossing technique. Gave patient names of
saliva sure and biotene products to help combat dry mouth
discomfort.
Evaluation
a. How will you evaluate care?
i. 6 month DHYG recall
b. Follow up charting
i. No plaque score due to beginning scaling while waiting for
DDS exam
ii. Recording probing depths
iii. Calculus detection
c. Patient OH behavior changes
i. Expect improvement/management of current probing
depths
ii. Expect decreased BOP
iii. Expect decreased probing depths on posterior teeth near
restorations