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Treatment Plan #2
Rachel Oakes
I. Assessment (Preliminary Phase)
A. Patient Interview: “I haven’t been to the dentist in 5 years and need my teeth
cleaned.”
allergies. Patient has had her gallbladder removed and gastric sleeve surgery
within the past year. Patients blood pressure is 130/85. Patient does not receive
yearly dental exams but recently had a full dental exam on 2/14/18. Patients last
Penicillin products. Patient states that she brushes her teeth once a day in the
Medications include:
granules present bilaterally on lips, one 1x1mm small, circular, red cheek bite on
the buccal mucosa between #15, #18, maxillary frena is red, oral pharynx is
generalized red, Bilateral tori on mandible, almond-shaped tori on the hard palate,
tongue has generalized coating, tongue is fissured and has a scar on the midline
from a previous tongue piercing, third molars #1, #16, #17 are partially erupted;
Contour of Interdental Papilla: Generalized pointed/normal, #5, #6, #10, #11 are
2/14/2018.
II. DH diagnosis
A. Level of Health: At this point in time, the patient is in fair physical health and fair
oral health. I believe that the patient has the ability to understand and provide
themselves adequate home care upon proper instruction and with the possible use
III. Plan
extraction.
C. Phases of treatment: One appointment treatment plan with six month recalls.
A. 1st appointment:
pressure. Assess extra-oral health and intra-oral hard and soft tissue conditions. Begin
probing and calculus detection while charting all findings. Disclose patient and record the
new plaque score. Discuss OHI with patient including incorporating flossing into her
routine and brushing her teeth at night. Introduce and demonstrate the Bass technique and
C-shaped flossing technique. Discuss switching to a diet soda beverage instead of full
flavor; inform patient to drink sodas all at once and not to sip on it all day.
Begin scaling using area specific Gracey curettes to remove supra and subgingival
calculus. Following this procedure, check effectiveness with an 11/12 Explorer. Once
calculus is effectively removed, begin polishing with a fine prophy paste due to minimal
staining and floss patients full mouth. Post-op instructions include to tell the patient about
potential discomfort after appointment. For pain, they may use an NSAID of their choice
as needed. Also advise to rinse mouth with salt-water and to avoid spicy food. Send
patient home with a Biotene sample to help with medication induced xerostomia.
References
Wynn, R. L., Meiller, T. F., & Crossley, H. L. (2016). Drug information handbook for dentistry:
Including oral medicine for medically-compromised patients & specific oral conditions (22nd
Wilkins, E. M. (2017). Clinical practice of the dental hygienist (12th ed.). Philadelphia: Wolters
Kluwer.
Myers, S. L., & Curran, A. E. (2015). General and oral pathology for dental hygiene practice.