Академический Документы
Профессиональный Документы
Культура Документы
Assessment Findings
2. Buprenorphine: taken once daily; maintenance 2. Headache, nausea, vomiting, sweating, constipation,
treatment of opioid dependence insomnia; signs and systems of withdrawal; xerostomia
1. Last dental visit: 02/05/2017 1. High bacteria count, calculus buildup, caries
2. Type and date of most recent x-rays taken: N/A 2. Undiagnosed dental problems
3. Gums bleed when flossing 3. Gingivitis, infection, high bacteria count, periodontal
disease, interproximal caries
4. Prone to many cavities at dental checkups
4. Gingivitis, infection, high bacteria count, periodontal
5. 3 sugary/sports drinks a day disease, interproximal caries
5. Caries, demineralization
1. Sthenic 1. None
2. Mesognathic 2. None
6. Slight palatal tori; slight unilateral mandibular tori eti: 7. Hight bacteria count, increased biofilm, calculus,
developmental gingivitis, periodontitis, oral cancer, defective
restorations, demineralization
7. Coated tongue posterior dorsal surface eti: sinus
drainage 8. None
8. Class I occlusion R/L molar; Class I occlusion R/L canine 9. Malocclusion, esthetics, TMJ complications
20. Mesial incisal fracture #8 19. Tooth decay, excess wear on incisal edge
21. Caries: #1MO, #2MO/DO, #3M, #4F, #11F, #12 MODF, 20. Sensitivity, tooth decay, esthetics
#14MO, #18M, #19DO, #20DO, #21F, #29F, #30MODF
21. High bacteria count, increased biofilm, calculus, gingivitis,
periodontitis, demineralization
Periodontal Case Type: 2 Plaque Score: 2.33 Fair Bleeding Score: 2.87%
Problem Etiology
1. Periodontal Case Type 2- Slight Periodontitis Plaque buildup, poor brushing and flossing methods, behavioral
factors, high bacteria count, recession, TMJ complications, caries,
infection, disease progression
3. Poor Diet/Caries Poor eating habits; lessen sugar intake and frequent snacking on
cariogenic foods/drinks to reduce caries
Planned Interventions
Expected Outcomes
LTG 1: Pt. started with a plaque score of 2.33 and will aim to 1. Define plaque. A plaque score will be
End of 1st
lower plaque score to 1 or less. evaluated at every appointment using
Apt.
disclosing solution. Teach bass method
STG 1: Patient will be able to define plaque and use
and have patient demonstrate at every
disclosing solution to determine where plaque buildup is by
appointment. Make changes if needed to
the 2nd visit.
produce a better plaque score.
STG 2: Patient will learn bass method and how this
technique will reduce plaque. She will be able to demonstrate
by the 2nd visit on herself and the typodont
STG 3: She will reduce her bacteria count in the mouth by
lowering her score .3 at each appointment visit until she
reaches a plaque score of one or less
LTG 2: Patient will achieve to stop the progression of her End of 2nd
2. Recap plaque and brushing learned from
periodontal disease Apt.
last appointment. Define periodontal
STG: Patient will be able to identify periodontal disease and disease and use current x-rays to help
understand that it is irreversible. explain bone loss. Teach flossing method
and evaluate to make any changes. Take
STG: Patient will demonstrate proper flossing technique
FMX and use x-rays to visually explain
learned in pt. ed. and understand why flossing is important
bone loss and point out dark spots
to halt the progression of bone loss and reduce interproximal
indicating caries between teeth.
caries
3. Recap flossing and periodontal disease
STG: Patient will decrease bleeding point score by 2nd visit
from previous appointment. Discuss how
and set up recall appointment in the next 3-4 months.
diet can affect her teeth and the cause of
LTG 3: Patient will be educated on how her diet and her caries. Define caries and explain the
nutritional habits are the cause of her caries importance of fluoride for it will help End of 3rd
STG: Patient will be able to describe the caries process by remineralize those areas. Also advise pt. Apt.
understanding what affects caries has on the teeth and how to snack to on non-cariogenic foods
they are formed on the teeth. instead.
Appointment Plan
Appt # Plan for Treatment Plan for Education, Counseling or Oral Hygiene Instruction
Medical/Dental hx Data Collection
1 Radiographs- FMX
Intra and Extra Oral Exam
Dental Charting
Periodontal Assessment
Bleeding Score/Plaque Score
Informed Consent
Medical/Dental hx UR UL Discuss plaque score and teach patient how to reduce this
2 Bleeding Score/Plaque Score score by next visit. Discuss how plaque causes diseases such
Sickle Scale Evaluation as gingivitis and periodontitis if left untreated. Teach bass
Scale Maxillary Rt/Lt Quadrant method and have patient demonstrate at every appointment.
Make changes as needed to produce a better plaque score.
Use disclosing solution to determine where plaque buildup is
located and spots the patient is missing.