Treatment Plan #1 Ashleigh

Cooling

I. Assessesment

a. Patient Interview
75 year old male patient
Chief complaint: I want to get my teeth cleaned
Has been on 6 mos RC visits at College since 2007
b. Medical/Dental History
Tremors/seizures- medicated
Taking Keppra, Lamotrigine, Lipitor, 81mg Aspirin.
Last cleaning was 10/2015
Pt is prescribed Prevident 5000
c. Social History
WNL
d. Vital Signs
BP 135/85 which patient stated is lower than norm
e. Intra-oral/extra-oral exam
Extra-oral exam within normal limits
Intra-oral exam WNL; Fordyce granules buccal
mucosa
Generalized attrition
Abfractions lower anterior 22-27
Class I occlusion L-R
Class I furcas 2, 3, 18, 19, 30, 31.
Gingiva pink, firm and necrotic.
Multiple restorations
Crowns 3, 8, 18, 21, 29, 30,31
f. Periodontal exam
Generalized probing depths 4mm or less
Localized 5mm on ML #3
Generalized recession
Class I Furcation involvement #2, 3, 18, 19, 30, 31
Bleeding on 2, 3, 5, 15, 19, 31
g. Radiographs
4BWX taken 11/2013
Shows horizontal bone loss

II. DH Diagnosis

a. Level of Health
Fair level of health
 No limitations, no treatment modifications
b. Diagnosis
Perio case type Moderate generalized
Calculus class B

III. Plan

a. Consultations Necessary
Family physician- follow up regarding tremor
episodes
b. Treatment Goals
Minimize recurrence and progression of disease.
Reduce or at minimum maintain probing depths.
Arrest further attachment and bone loss.
Keep furcations from progressing.
c. Addresses Phases of Treatment
a. Preliminary Phase
i. Obtained pts medical, dental and social
histories. Perform I/O, E/O examinations.
ii. Treatment was compromised due to patients
having tremor episode and not being able to
continue care.
b. Phase I- therapy
i. Biofilm control-Introduce patient to homecare
aids such as power brush and floss aids.
Educate patient on biofilm control to stop
progression of periodontal and caries disease.
ii. Calculus removal- handscale using gracey
currettes.
iii. Address biofilm traps associated with existing
restorations and abfraction areas.
c. Phase II- Surgical
i. n/a
d. Phase III- Restorative
i. Discuss possible composite placement on
abfraction areas.
e. Phase IV- Maitenence
i. 6 mos RC appointments
ii. Discuss bass technique w/ 2 min brush time
iii. Show patient areas to pay special attention.
Abfraction areas, upper right molar region and
upper and lower lingual of anterior teeth.
iv. Discuss prober C wrap floss technique
 v. Make sure patient is able to properly floss
restorations
vi. Educate patient on using Prevident 5000, dont
rinse.

IV. Implementation

f. Consultation
Needs to follow-up w/ family physician.
g. Instruments and Methods
Hand instruments - Area specific curettes, graceys
Universals
h. Homecare Aids
Oral B Vitality
Floss aid
i. Anesthetic
n/a
j. Prescriptions
Prevident 5000

V. Evaluation

a. How will you or how did you evaluate care

Did patient use power tooth brush/ prescription
toothbrush?
Was sub/ supra calculus removed?
Does patient understand/ accept need for homecare
routine and use homecare aids?
Did patient address tremor/seizure w/ family
physician?
b. Follow up charting
Improve/ maintain perio charting at 6 mos interval
appointments
Improve bleeding
Furcations maintained?

c. Radiographs
Horizontal BWs at next appointment to evaluate
deposits and bone level.
d. Patient OH behavior changes
Does patient care about oral hygiene
Does patient understand OHI directions
Has patient used toothbrush and homecare aids to
improve OH