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Treatment Plan Assignment Lauren Farmer Kylie Hill Mackenzie Digmann Callie Verschoore Kirkwood Community College

The treatment plan summarizes a patient's dental needs and proposed treatment. The patient has moderate periodontitis with bleeding gums, sensitive teeth, and cavities. The plan is to improve her oral hygiene with a soft brush and flossing, scale and polish her teeth to reduce plaque and staining, and apply fluoride varnish. The dentist will also restore her cavities. Her oral hygiene will be re-evaluated in 4 months to monitor her periodontal health and ensure her new routine is effective.

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145 views

Treatment Plan Assignment Lauren Farmer Kylie Hill Mackenzie Digmann Callie Verschoore Kirkwood Community College

The treatment plan summarizes a patient's dental needs and proposed treatment. The patient has moderate periodontitis with bleeding gums, sensitive teeth, and cavities. The plan is to improve her oral hygiene with a soft brush and flossing, scale and polish her teeth to reduce plaque and staining, and apply fluoride varnish. The dentist will also restore her cavities. Her oral hygiene will be re-evaluated in 4 months to monitor her periodontal health and ensure her new routine is effective.

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© © All Rights Reserved
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Treatment Plan Assignment

Lauren Farmer

Kylie Hill

Mackenzie Digmann

Callie Verschoore

Kirkwood Community College


I. Assessment
A. Patient has not received regular dental care. The patient’s last prophy and CMS were 9
months ago. The patients main concern “My teeth are really sensitive and my gums
bleed when I brush my teeth.” Food catches easily between teeth. Teeth are sensitive
to all drinks, especially high energy drinks.
B. Medical concerns: Patient has a history of frequent kidney infections and a family
history of diabetes, high blood pressure, osteoarthritis and osteoporosis. Medications:
81 mg aspirin, (Hydrochlorothiazide) Microzide, OTC antihistamines, 1000 mg
calcium citrate and 2000 IU’s Vitamin D. Dental habits: Patient brushes with a hard
bristled toothbrush and has not changed it since her last hygiene appointment. She has
trouble with flossing and gives up quickly. She uses a nightly phenol rinse to see if it
will decrease her bleeding.
C. Patient did not mention any habits.
D. No vital signs were taken; take at next appointment.
E. Extra-oral exam: submandibular, submental and preauricular nodes were palpable and
tender. Intra-oral exam: within normal limits.
F. Periodontal case type: Moderate periodontitis. Bleeding Index: 55%, Plaque Free
Score: 30%, Class 1 furcation involvement on teeth #15, 18, 19, 30, and 31.
Generalized < 3 mm probing depth on maxillary and mandibular anteriors with
Generalized > 4 mm on maxillary and mandibular posteriors.
G. CMS from last visit 9 months ago

II. Dental Hygiene Diagnosis


A. Level of health: mild systemic disease, ASA II. She is on an allergy medication
meaning she has allergies, she is also on aspirin (81mg) and microzide which are both
used for heart health such as myocardial infarction and hypertension. There are no
vital signs recorded so there is no way to know if these medications are working to
control her blood pressure
B. Moderate periodontitis because probing depths are generalized >4 on posterior teeth,
bleeding on probing, furcation involvement on teeth #15, 18, 19, 30 and 31. She is at
risk for caries because she has stated that she does drink energy drinks, but her teeth
are sensitive. She also does not do any interproximal cleaning and she already has
caries on teeth # 4, 18, and 30.
III. Plan
A. Consult: General dentist for restorative work, possible consult with periodontist.
B. Treatment goals
-Have patient develop daily routine brushing 2x daily and flossing 1x daily and
use floss picks/interdental brushes in areas of furcation.
-Reduce bleeding index.
-Reduce plaque score.
-Prevent periodontal pockets > 4 mm from progressing
-Put patient on a 6 month recall
C. Preliminary Phase: information was gathered at assessment, no emergency treatment
needed.
Phase I (Therapy):
- Biofilm control: Plaque score, oral hygiene routine
- Additional Preventive Measures: Fluoride
- Calculus Removal: Hand scale
- Corrective Restorative Irritants: N/A
- Restorative Caries Control: Needed on teeth #4, 18, 30
Outcomes Evaluation of Phase I:
- Probing Depths: stabilized probing depths
- Clinical Signs of Inflammation: decrease in bleeding index
- Dental Biofilm Control: lowered plaque score
- Patients Participation: daily oral hygiene; soft toothbrush and flossing
Phase II (Surgical): Not needed
Phase III (Restorative):
- Final restorations: restore carious lesions
- Fixed/removable prostheses: N/A
Evaluation of Overall Outcomes: restoration is not mobile, no pain, no recurrent
caries around the restoration
Phase IV (Maintenance):
- Appointments for continuing care and supervision: 4 month recall
- Refining biofilm control technique: using a soft bristled toothbrush, flossing
multiple times a week

IV. Implementation
A. After reviewing medical history, dental history, intra-oral exam, extra-oral exam and
collecting data; go over OHI and dietary consult.
1. Brushing- Change the patients tooth brush to soft bristles, the patients study
models show multiple areas of recession that could be from the hard bristled
toothbrush she was using since her previous appointment 9 months ago. Tell
the patient to use soft circular motions and angle the toothbrush at 45 degrees.
2. Flossing- Stress the importance for flossing 1x daily. Demo the proper flossing
technique by wrapping the floss in C-shape around teeth then have the patient
demo flossing (critique if necessary) and ask if she would be able to floss at
home. By using the “Tell-Show-Do” process the patient should feel more
confident in flossing at home.
3. Periodontal disease - Explain to the patient probing depths, 1-3 mm are normal
depths, 4 mm or higher can mean concern for periodontal disease. Show
patient that they have generalized >4 mm on their posterior teeth. They have
furcation involvement on teeth # 15, 18, 19, 30 and 31, because of bone loss.
Plaque and bacteria will get into the furcation causing problems with caries.
4. Dietary consult- Patient may benefit from a diet consult, patient had stated her
teeth are sensitive to “high energy drinks”. Ask the patient how frequently she
is consuming those drinks and explain how those drinks play a role in the
caries process. (Sugar+Bacteria from plaque= Acid Acid+healthy tooth=
Decay)
B. Administer anesthesia
C. Scale full mouth by hand
D. Polish full mouth with medium grit prophy paste because of high plaque score and
staining.
E. Floss full mouth with unwaxed floss.
F. Fluoride varnish full mouth. Post operative instructions: can eat and drink right away,
no alcohol for a couple of hours, don’t eat excessively hot or cold items such as soup,
coffee, or ice cream. Wait to brush teeth for six hours or brush the next morning.
G. Dentist will come in for a caries consult and talk to patient about restoring her carious
lesions.
H. Make appointment for restorations on teeth #4, 18, and 30.

V. Evaluation
A. How will/did you evaluate care: Would evaluate care with comparing charting,
radiographs, and improvement of oral hygiene.
B. Follow up charting: Chartng full mouth, probing, recession, furcation, bleeding, and
plaque score to see improvement, stabilized, or worsening of periodontitis.
C. Radiographs; Bitewings in one year.
D. Patient oral hygiene behavior changes: New soft bristled toothbrush, flossing multiple
times a week, lower plaque score, lower bleeding index.
References

Boyd, L., Wilkins, E., Wyche,C. (2017). Clinical practice of the dental hygienist. Philadelphia,

PA: Wolters Kluwer. (12) 398, 409, 440.

Crossley, H., Meiller, T., Wynn, R. (2018). Drug information handbook for dentistry including

oral medicine for medically compromised patients & specifi oral conditions. Hudson,

OH: Lexicomp. (24)

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