Treatment Plan #1 Assignment

Heather
Wilhelmi
Dana Arenas
Sarah Moore

1. Assessment
A. 21 white female
B. Dental hx- regular checkups until last year medical hx- recent mono,
panic attacks, insomnia
C. Social drinker, poor diet
D. Temp 100.7, pulse 90, respirations 18, BP 108/68.
E. Bilateral, palpable, tender cervical submandibular lymph nodes,
fetid breath, and dry mouth.
F. Perio exam- pocket depths of 3-4mm
G. G. Radiographs of anterior periapicals
2. Diagnosis
A. Gingivitis
3. Plan
A. Consult dentist for restorations of caries, and for a prescription for
chlorehexadine. If patient interested consult for smoking cessation.
B. Treatment goal is to eliminate ANUG through reducing risk factors
and increasing the patients oral hygiene knowledge thus lessening
the pain, bleeding, and improve E
C. Treatment Phases:
a. Remove Plaque with ultrasonic and hand scaler
i. split into separate appointments if necessary
ii. coordinate with Dentist for restorations
iii. utilize anesthesia for patient comfort if needed
iv. evaluate progression, make changes as needed at each
appointment
v. instruct on homecare with prescription for chlorhexidine
also to be assessed at each appointment and changed if
needed

b. During the separated appointments:

i. evaluate diet and discuss changes
ii. talk about smoking cessation
iii. give tips for helping with xerostomia and bad taste
**Be sure to focus on one thing at a time. Dont try to
fix it all at once.
4. Implementation
Remove plaque using ultrasonic and hand scaler. May need to split
appointments and scale in sections using anesthesia. Coordinate the
appointments with the dentist to have caries restored. At the first
appointment instruct the patient on brushing and flossing techniques.
Brush with a soft toothbrush angled toward the gingiva in small circular
motions. Use chlorhexidine to brush and rinse one time in the morning
and again after her last daily meal. Floss by sawing it through the
contacts and wrapping around the tooth to not injure the gingiva or
cause pain. Discuss nutrition and how this can be changed to help her
oral health. Give her information for smoking cessation programs and
motivate/encourage her. Since she complains of xerostomia and bad
taste explain that is caused by the medicine, lunesta. Give her tips to
help with that such as rinsing with H20 after meals and chewing trident
with xylitol. Explain the relationship of the acid in mouth and saliva
and how water and gum helps combat this. At follow up appointments
assess home care, smoking habit, nutritional diet and xerostomia
improvement. After all cleaning complete allow tissue to heal for
several weeks then have her return to assess the treatment

effectiveness and health of tissue, polish, and apply fluoride. Schedule

a 6 month appointment recall. Refer her to using a toothpaste such as
crest pro-health and if prefers using a mouth rinse recommend using
one without alcohol so it is less abrasive and irritating to the gingiva.
5. Evaluation
Most of the care will be evaluated at follow up visits for this patient.
Todays visit creates a baseline for the future. This patients
inflammation and bleeding will need to be assessed at the next visit to
determine if the care plan needs to be modified. She should be put on
a 6 month recall maintenance appointment. Care will be evaluated by
comparing perio charts from today and one that will be done in 6
months. Bleeding on probing will also need to be evaluated for
improvement. Radiographs should be taken again in a year or when
the dentist prescribes them. Radiographs should be compared to the
ones we have now for improvement or lack of. Radiographs taken
today are blurry, but I do not believe they show that the patient has
periodontitis. If the patient improves her at home care her ANUG and
gingival health should greatly improve at the next visit. Documentation
of gingival description is very important for this patient. Since
eliminating ANUG is the goal this will be mainly assessed thru gingival
description in documentation/notes. The medications that this patient
is on should also be documented along with the other health problems
that she has been experiencing that have contributed to her overall

oral health. Her smoking habits and details about her OH should also
be documented so they may be compared at future appointments.
Wilkins, E. (2013). The professional dental hygienist. In Clinical Practice of the
Dental Hygienist (11th ed., pp. 6-9). Philadelphia, PA: Lippincott
Williams & Wilkins.