INITIAL PERIODONTAL

CHART (1/19/17)

Generalized Periodontal Probe

Depths of 3-10 + mm
118 Readings 4 mm and above
129 Bleeding Points
Localized Slight Recession
Localized Class 1-II Furcation
Involvement
Localized Class 1 Mobility
 DENTAL HYGIENE DIAGNOSIS

Tissue Description
Color: Generalized severe marginal and papillary hyperemia
Contour: Generalized severe enlargement with localized recession
Consistency: Generalized severe edematous tissue
Bleeding: Generalized moderate spontaneous upon probing
Clinical Assessment Markers: Localized recession, mobility, furcation
involvment
Statement of Inflammation: Generalized severe marginal and papillary
inflammation
Periodontal Case Type III-Moderate Periodontitis
Deposit Rating: Supra-Gingival Calculus: 3, Sub-Gingival Calculus: 5
 MICROSCOPE EVALUATION

Risk Factor C-high risk; high counts of spinning

rods/spirochetes, highly mobile
PRE-TREATMENT INTRA-ORAL PHOTOS
PRE-TREATMENT INTRAORAL PHOTOS
 RISK ASSESSMENT

Systemic Risk Factors: Behavior was a large risk factor, as Juan had gone his whole life
without professional hygiene therapy. He was also brushing only once per day, with a
manual toothbrush. Juan tried to floss once per day, however was not using any other
home care aids.
Periodontal Risk Factors: Moderate dental biofilm (plaque), generalized severe calculus,
tooth position (crowding in mandibular anterior teeth)
Caries Risk Factors: Moderate decay found in maxillary molars
Client Centered Goals: Juan wanted his teeth to be clean, as he had never had
professional hygiene therapy, and he wanted to fix any problems he was having, as his
upper left teeth especially were sensitive.
Interventions: Providing a full comprehensive examination, oral hygiene instruction,
dental hygiene therapy, restorative work.
Expected Outcomes: Calculus and biofilm would be removed, allowing tissue to heal
and periodontal pockets to reduce. A reduction in bleeding points would also occur, all
allowing the patient to move towards normal, healthy, gingiva. Juan would also improve
home care, and keep up with regular maintenance appointments. Any restorative work
would be performed.
 TREATMENT PLAN

Taking into account Juans periodontal assessment, risks, behaviors, and

chief concerns, a treatment plan was formulated.
The original treatment plan consisted of six appointments:
1. Full Mouth Set of Radiographs (D0210); a Panoramic radiograph
(D0330); and Oral Hygiene Instruction (OHI) (D1330)
2. Comprehensive Oral Evaluation (D0150); Non-Surgical
Periodontal Therapy (NSPT) completed by quadrant (D4341); OHI
(D1330)
3. NSPT by quadrant (D4341); OHI (D1330)
4. NSPT by quadrant (D4341); Gingival Curettage on teeth #s 9, 10,
12 (D4999); OHI (D1330)
5. NSPT by quadrant (D4341); OHI (D1330); Fluoride Varnish
(D1206)
6. Re-evaluation Appointment