Kaylee Blum

I.

● Patient Interview: Patient reports he knows he has a lot of deposit on his teeth and is

anxious to have it removed.

● Medical/Dental History: Patient is a previous smoker and used sucking on lemon

lozenges to help quit, he states he is now addicted to the sour taste. Patient has minor

vision loss in one eye as well as minor hearing loss. He has been seeing a doctor for

cluster headaches and high blood pressure. He had hernia surgery 24 years ago and has

had no issues since. The patient has followed preventative care recommendations for six-

month maintenance intervals for years. He currently takes Amlodipine, Ramipril, and

Omeprazole. The patient says that he brushes 2-3 times daily with a medium bristled

toothbrush and fluoridated toothpaste. He states that he flosses daily. He demonstrates a

vertical and horizontal scrubbing motion when brushing.

● Social History: He is a sales representative for a national company and is on the road

most of the time. He is married and has children who are grown and live in another state.

● Vital Signs: BP 140/88. Pulse: 70 bpm. Respiration: 12 breaths/minute.

● Intra-Oral/Extra-Oral Examination: A circumferential redness in the mucosa above the

extracted upper right molar is present, most likely a vascular hyperemia found in

edentulous areas where the width of the keratinized mucosa is decreased. His gingival

tissues appear generalized pink with localized areas of inflammation, especially on the

mandibular lingual surfaces. There is visible supragingival calculus present on the lingual
 surfaces of the mandibular anterior teeth. The patient has crepitus bilaterally, he states he

wears a night guard when he remembers. All other extraoral findings are WNL.

● Periodontal Examination: Patient had generalized 2 and 3 mm probing depths with

localized 4, 5, and a few 6 and 7 mm probing depths in posterior areas. Bleeding Index

20%. Plaque Score 25%.

● Radiographs: Full mouth CMS present.

II.

● Level of Health: The patient is moderately healthy. He has quit smoking but has now

picked up a habit of sucking on lemon lozenges. Based on his height, weight, and blood

pressure he could be considered overweight, and his blood pressure would be considered

high given his age, however, he is taking meds and seeing the doctor for his high blood

pressure.

● Diagnosis: Patient has generalized gingivitis and localized slight periodontal disease.

Patients probing depths are mostly 1-3 mm with localized 4 mm probing depths and one

probing depth of 5 mm. Light to moderate bleeding upon probing noted. His gingival

tissues appear pink with localized redness in the mandibular lingual areas. Generalized

recession visible in intraoral photographs.

III.

● Consultations Necessary: Patient could see an oral pathologist if interested for his painful

ulcers that he noted he gets. No other consultations necessary.

gingivitis. It is important for the patient to switch to a soft bristled toothbrush as he is

currently using a medium bristled brush that is likely causing some abrasion that is seen

in intraoral photographs.

● Phases of Treatment:

○ Preliminary - Patient does not have any emergent needs, will be able to go straight

on to initial.

○ Initial - Complete full mouth scaling, use ultrasonic scaler on mandibular anterior

linguals where calculus is very heavy. Follow up with hand scaling and complete

full mouth hand scale followed by full mouth polish and floss.

○ Surgical phase - No surgeries needed

○ Restorative - If dentist notes any decay during exam complete restorations as

needed and decided by dentist.

○ Maintenance - 6 month recalls

IV.

● Consultation: Suggest brushing twice a day with a soft bristled manual or power brush,

correct “scrubbing” motion to lightly brushing in circles, encourage flossing daily and go

over flossing technique and have the patient repeat what I have shown him using a hand

held mirror. Recommend fluoridated toothpaste and a non-alcohol mouth rinse.

● Instruments Used: Start with ultrasonic for mandibular anterior linguals to remove heavy

calculus. Follow up with hand scaling all four quadrants. Complete full mouth polish
 with rubber cup prophy and medium prophy paste. Place topical fluoride varnish on all

teeth at the end of the appointment.

● Anesthetic: No anesthetic needed unless the patient ends up complaining of any pain or

sensitivity when completing tx.

● Prescriptions: Suggest Prevident 5000 toothpaste for patient to be exposed to extra

fluoride to help protect areas of recession and prevent sensitivity in those areas.

Encourage the patient to continue seeing his primary doctor to stay on top of all other

medications that are recommended by his doctor.

V.

● Evaluation of Care: Initial assessment of the patients needs were correct. Phases of

treatment are set in order of the best way to care for the patient and complete all of the

patients dental needs. Based on the patient's health status and health history, we could

review nutritional counseling to the patient and reiterate oral hygiene instructions and the

importance of continuation of care. Scaling type was appropriate and calculus removal

was effective with Ultrasonic and Hand Scaler. Plaque removal was effective as full

mouth polish was completed with rubber cup prophy. Appropriate fluoride treatment was

planned and completed due to patients areas of recession.

● Follow up Charting: Complete full mouth probing to evaluate if there has been any

improvement of probing depths and if there is any reduction of BOP.

● Radiographs: Recommend 4 BWs at next recall appointment due the date of current set of

radiographs being unknown.

2x/day. Encourage patient to continue working on flossing daily using the C-shape

technique.

References:

Boyd, L., Mallonee, L., & Wyche, C. (2020). Wilkins’ clinical practice of the dental

hygienist (13th ed.). Jones & Bartlett Learning.

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

dentistry (24th ed.). Lexi-Comp Inc.