Treatment Plan #2

Amy Formanek

I. Assessment
a. Patient Interview
66 year old male

56 of Middle Eastern decent with slight accent but good

English

Patient comes to regular dental exams since March of 1987

He has family in and out of state

He seems knowledgeable and aware of Oral health and needs

Snacking habits are with nuts mostly

b. Medical / Dental History

He has generalized slight periodontal disease

Implant for #30, placed 06/19/2014

Extractions for #30, 1, 16,17 and 32

Crowns on #14 and 15

Root Canal treatment on #14

Fillings on #2, 3, 10, 18, 19, 20, 29 and 31

Has Hypertension diagnosis and taking medication to control

All medications include: Aspirin- since 11/2012, baby aspirin

prescribed by Dr. to prevent cardiovascular events. This could

cause excess bleeding during treatment. Multivitamin- since

10/2014, supplements with no effects on dental /treatment.

 Cozaar 500mg 1x daily- since 11/2012, treatment of his

hypertension. This may cause dizziness.

Has issues with right rotator cuff

Cardiac Catherization done in June or July of 2007- patient

could not remember exact month

No known allergies

c. Social History

Has never smoked

Average family man

d. Vital signs

2/24/2016- Blood Pressure was 130/88

3/2/2016- Blood Pressure was 130/80

Approximately 134 pounds

e. Intra-Oral / Extra-Oral Examination

Extra-Oral: TMD deviation, asymptomatic, patient did not

notice it

Intra-Oral: Patient noticed a ridge on #19 near restoration, Dr.

examined and stated it was a fracture line and to monitor at

recall. Mandibular tori presented lingual to #27/28 and

#21/22. Lump on left dorsal of tongue. It measured 11x8mm

and was adjacent to crown and patient stated it has been

there for years without any changes in color, size or

 symptoms as it has been asymptomatic. All soft tissues have

melanin pigmentation. 27 teeth total but attrition located

#9/10 and #23-27. #28 and 24 have abfractions. Class l

furcation involvement on #14. 40% overbite and 3mm

overjet.

f. Periodontal Examination

Generalized slight periodontal disease

Class B calculus

4mm pockets in posterior around crowns, measured

02/24/2016

FM probing last done 10/31/2014 with generalized probing

depths 3mm or less with the exception of #20 Distal and #19

Distal at 4mm.

g. Radiographs

He has only had bitewings and periapical films, targeting

#30/19

Bitewings show #30 pre implant and post implant

Shows small bone loss and small pieces of calculus

II. DH Diagnosis
a. Level of Health
Overall level of health is good

Patient does okay with upkeep

b. Diagnosis
 Generalized Slight periodontal disease

III. Plan
a. Consultations Necessary
General Dentist

Oral surgery

Periodontist

b. Treatment Goals

Improve Plaque score and keep up or better patients

homecare

c. Address Phases of Treatment

Assess data for treatment

Improve homecare

Create a flossing routine and better brushing strokes

Minimize probing depths

Evaluate implant

Set up a 6 month recall

IV. Implementation
a. Consultations
Patient would need to see Dentist at 6 month recall

Periodontist if periodontal disease worsens

Oral surgery for any restorations on existing or new fillings

b. Instruments and Methods Used

 Hand instruments- Area specific curettes and sickle scaler

Oral-B neutral foam given to strengthen structure around

crowns and prevent more interproximal decay

c. Homecare Aids

Suggested an electric toothbrush to aid in brushing strokes

Floss reacher to begin an easier flossing routine

d. Anesthetic

No anesthetic needed for this patient

If it needed to be administered there would be no

complications with meds

e. Prescriptions

Prevident 500 toothpaste could be an option if condition

worsens

Chlorohexidine rinse could be an option if condition worsens

V. Evaluation
a. How I evaluated care
Patient showed up to the next appointment with a new

electric toothbrush to try showing improved interest

Plaque score went down 20% from 02/24/2014 to 03/02/2016

In the future I hope he finds his electric toothbrush helpful and

uses that along with a daily flossing routine

Because of current knowledge patient is at a 6 month recall

b. Follow up charting
 Improved probing depths

Arrest carries

c. Radiographs

Make 4 new bitewings at next visit and monitor #20 and #19

No calculus present on new radiographs

d. Patient OH behavior changes

Continued lower plaque score

Patient using electric toothbrush effectively

Patient have less interproximal calculus

References

Wynn, R. L., Meiller, T. F., & Crossley, H. L. (2014). Drug information

handbook for dentistry: Including oral medicine for medically

compromised patients & specific oral conditions (20th ed.). Hudson,

OH: Lexicomp.

Wilkins, E. M., & Wyche, C. J. (2013). Clinical practice of the dental

hygienist (11th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott

Williams & Wilkins.