Treatment Plan Assignment

Lauren Farmer

Kirkwood Community College

1. Assessment

a. Patient Interview: Susie Smith is a 20 year old female. She came in through

DIAG and had an exam on 5/28/19 and currently has no dental pain.

b. Medical history: Currently seeing Dr. Jennifer Beck at UnityPoint Clinic. Is

smoking a pack of cigarettes a day, has been smoking for 5 years and is somewhat

interested in quitting smoking. The patient has bronchial spasms and uses an

albuterol inhaler 2-3 times a week. She has the dermatological problem of

Hidradenitis Suppurativa. Mental health; generalized anxiety disorder and panic

attacks.

Medications:

1. Albuterol- used for bronchospasms 2-3 times a week, did not bring to the

first appointment but did bring to the 2nd and 3rd appointment. Effects on

the mouth: xerostomia, candida infection in the back of the throat. No

effect on local anesthesia.

2. Nexplanon - used for birth control. No effect on the mouth. No effect on

local anesthesia. Remind patient that birth control is ineffective when

using antibiotics.

3. Alprazolam - used for anxiety and panic attacks. Effects on the mouth:

xerostomia. No effect on local anesthesia

4. PreviDent 5000+ toothpaste

Dental History: Patient is sensitive to sweets and pressure. Last cleaning was over

2 years ago. Clicking in the jaw and grinds their teeth. Uses a manual toothbrush.
 Uses Crest Sensitive and PreviDent 5000+ toothpaste. Never flosses teeth,

brushes once a day. Uses listerine gold mouth rinse. Snacks on salty foods. In

between the first and second appointment on 6/17/19 she had #19 O resin

composite.

c. Implications treatment of special needs patient:

■ Anxiety and panic attacks: Want patient to feel incontrol, have them raise

their hand when they need a break. They can hold the suction during

ultrasonic scaling. Administer local anesthetic when they say they are

ready. Her boyfriend came back during the 2nd appointment to hold her

hand during the injections. For the 3rd appointment I held her hand to

calm her down.

■ Bronchial spasms: ask the patient to bring albuterol inhaler during the

appointment. Question on when it happens and what triggers it, the patient

said it happens randomly 3x a week. Control of the suction to keep the

water away from the back of the throat and they can stop the treatment by

raising their hand if they feel a spasm coming.

■ Hidradenitis Suppurativa: is a painful dermatologic disease that involves

lumps and drainage tunnels underneath the skin of areas that rub together.

The patient can be in pain and it may be hard to lift up their arms, modify

home care.

d. Habits: Smoking a pack a day

e. Vital Signs:
 ■ 1st appointment (5/31/19): BP 104/76

■ 2nd appointment (6/21/19): 100/65

■ 3rd appointment (6/28/19): BP 106/70

f. Extra-oral exam: Yellow nails, bilateral TMJ clicking, thyroid gland enlarged.

During the 2nd appointment noticed an enlarged lymph node behind their left ear,

it had gotten smaller by the 3rd appointment. Assumed it was because of the

composite they had on #19.

Intra-oral exam: Fordyce granules on lips, tonsils absent, hairy tongue, coating on

the tongue, cheek bite by #6 on the corner of the lips. By the 2nd appointment

they no longer had hairy tongue, they had a slight coating on the sides of their

tongue, and the cheek bite had gone away. The 3rd appointment was the same

finding as the 2nd appointment. They had 26 erupted teeth, generalized

remineralization, generalized medium yellow extrinsic staining. Class 1 occlusion

with anterior open bite.

g. Periodontal Examination: Gingiva was generalized red, pointed, knifed edge,

spongy, and inflamed. Bleeding was spontaneous on probing in the posterior.

Exudate was absent.

Periodontal Case Type: Generalized slight periodontitis. Probing depths

generalized 4 mm. Plaque score 1st appointment: 56%, 2nd appointment 20%,

and 3rd appointment 22%.

h. Relate oral changes based on special needs: Could have xerostomia based on the

medications she is taking. The chances of periodontal disease goes up in a person

 with panic attacks (Wilkins pg 1072). Tooth loss is more prevalent in people with

anxiety disorder (Wilkins pg 1072). This patient has had teeth removed in the past

(#2 and #15) and she has generalized slight periodontal disease both of these

coincide with her disorders.

i. Radiographs: Last radiographs were 5/28/19 they were bitewings and anterior

periapicals.

2. Dental Hygiene Diagnosis

a. Level of Health: ASA II - mild systemic disease or extreme dental anxiety. She is

taking Alprazolam for anxiety and panic attacks. She has bronchial spasms and

uses Albuterol inhaler. Both conditions are under control.

b. Generalized slight periodontitis because probing depths were generalized 4 mm

and see bone loss on the radiographs. People with panic attacks have an increased

risk of periodontal disease.

3. Plan

a. Consult: Will go to SURG on 8/28/19 for consult on removing #17 and 32.

Sealant on #14. Remineralization on #3, 5, 6, 12, 14, 19, 20, 29, 30, and 31. Resin

composite #19 occlusal.

b. Treatment goals:

■ Floss a couple times a week and work way up to flossing every day.

■ Brush 2x a day

■ Bush tongue
 ■ Keep periodontal pockets from increasing.

■ Reduce plaque score

■ Put patient on 6 month recall

c. Preliminary Phase:

Phase I (Therapy)

■ Biofilm control: Plaque score, oral hygiene routine to include brushing the

tongue, flossing and brushing daily

■ Additional Preventive Measures: Fluoride

■ Calculus Removal: Ultrasonic full mouth then hand scale full mouth

■ Corrective Restorative Irritants: none

■ Restorative Caries Control: In between the 1st and 2nd appointment

received #19 occlusal resin composite.

Outcomes Evaluation of Phase I:

■ Probing Depths: Stabilized probing depths

■ Clinical Signs of Inflammation: No bleeding on probing.

■ Dental Biofilm Control: Lower plaque score.

■ Patients Participation: Brush 2x a day, floss 1x a day, and brush tongue.

Phase II (Surgical): Remove teeth #17 and 32.

Phase III (Restorative):

■ Final Restorations: restore #19 O with resin composite

■ Fixed/removable prosthesis: None

Evaluation of Overall Outcomes: Restorations are not mobile, no pain, no

 recurrent caries around restorations. Healing well after removing #17 and 32.

Sealant has good margins and holds up.

Phase IV (Maintenance):

- Appointments for continuing care and supervision: 6 month recall

- Refining biofilm control technique: Look over plaque score, make

modifications if necessary. Continue flossing daily, brushing 2x a day and

brushing tongue.

4. Implementation

a. The first appointment was reviewing medical history, dental history, intra-oral

exam, extra-oral exam collecting data to go over OHI, and treatment planning the

next two visits.

■ Brushing - Start brushing 2x a day, using a soft bristled manual

toothbrush. Brush toward the gum line. The patient was having trouble

brushing her molars because she has tight cheeks, advised to close down

part way to make it easier to get the toothbrush back further. She had

asked how to brush her teeth when she can’t move her arms in the

morning. Suggested keeping a toothbrush or an interdental brush by the

bed.

■ Brushing tongue - Brushing tongue to remove some of the coating.

■ Flossing - Start by flossing a couple times a week, then work up to every

day. Use the tell show do method for teaching how to flossing by using a

see-saw motion and wrapping it around the tooth.

 ■ Periodontal disease - Explained to the patient probing depths 1- 3mm are

normal depths, 4 mm or higher can mean concern for periodontal disease.

Showed patient that they have generalized 4 mm on periodontal charting

and they are at risk for more bone loss if they do not keep up on home

care.

b. The second visit started with extra-oral exam, intra-oral exam going over

medications and medical history. The patient and I decided that the upper and

lower right quadrant would be a good side to start because they had a composite

on #19.

■ There was minimal coating on the tongue, the patient stated that she has

been brushing 2x daily and flossing daily. Show the plaque score and

made changes where necessary.

■ The instructor placed 20% Benzocaine topical for injections given.

Instructor administered 3.4 ml of 2% Lidocaine with Epinephrine

1:100,000 for IAL/B, PSA, MSA, and ASA on right side. Post operative

instruction given.

■ Started with the blue tip ultrasonic scaler. Once the large calculus was

removed, moved on with the green tip ultrasonic scaler. Then hand scaled

with the gracey 13/14, 11/12. 1/2 and sickle scaler.

■ Flossed the upper and lower right side of the mouth.

■ Post op instructions: you will stop feeling numb in about an hour. Until

then, do not test how numb you are by biting or chewing, instead touch
 with your fingers. Try not to eat until you are completely un-numb. You

may be sore, you can take whatever you would take for a headache.

c. The third visit started with extra-oral exam, intra-oral exam going over

medications and medical history. Finish the upper and lower left quadrant.

■ There was minimal coating on the tongue. Showed the plaque score and

made suggestions that were needed.

■ The instructor placed 20% Benzocaine topical for injections given.

Instructor administered 3.4 ml of 2% Lidocaine with Epinephrine

1:100,000 for IAL/B, Infiltration of # 14, MSA, and ASA on left side. Post

operative instruction given.

■ Started with the blue tip ultrasonic scaler. Once the large calculus was

removed, moved on with the green tip ultrasonic scaler. Once the majority

of calculus was removed went through and hand scaled with the gracey

13/14, 11/12. 1/2 and sickle scaler.

■ Flossed the upper and lower left side of the mouth.

■ Post operative instructions were to try not to eat anything or drink

anything too hot, it would be best to wait to eat when you are un-numb.

Don’t test how numb you are by biting, instead test with your fingers.

Take whatever you would take for a headache if you feel sore.

d. No flouride at any of the visits and no polishing. Patient will come back in 4

month and if their tissue is healthy then fluoride and polishing can be done then.

5. Evaluation
a. How will/did you evaluate care: Evaluate care by comparing charting,

radiographs, and improvement of oral hygiene

b. Follow up charting: Charting full mouth, probing, recession, plaque score,

furcation (if necessary), bleeding (if necessary) this would be to see an

improvement, worsening, or stabilizing of periodontal disease.

c. Radiographs: 4 bitewings in a year because they had radiographs 5/28/19. Look to

see if bone loss has stabilized or gotten worse.

d. Patient oral hygiene behavior changes: Plaque score stays the same or goes down.

Continue to see less coating on the tongue, continue to brush 2x a day and floss

daily.
 References

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

​ udson,
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OH: Lexicomp. (24)

​ etrieved from https://www.mayoclinic.or

Mayo Clinic Staff (2019) ​Hidrandentitis suppurativa. R

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