Date submitting plan: 3-11-14 Synopsis of Patient History Age: 32 Sex: Male Race: !ite eig!t: N"A P#op!$ %lass: 3 Pe#iodontal &$pe: %ase 2 1 st Appointment 2 nd Appointment 3 rd Appointment 'lood P#essu#e: 1()"1)(* S&+ 1* Rt 1(("1),* S&+ 1* Rt Pulse Rate: --* .3* #eg* N/ -)* .3* #eg* N/ Respi#ation Rate: 12* #eg* eas$* no#m* N/ 12* #eg* eas$* no#m* N/ Pla0ue Sco#e: 21-2 3ai# 'leeding Sco#e: 2(1))2 Amount and gene#al location of pla0ue: Mode#ate and gene#ali4ed %ont#ibuting facto#s fo# pla0ue #etention: %alculus* tobacco use* ca#ies* p#ost!esis* mout! b#eat!ing Current Oral Self Care Methods Type Frequency &oot!b#us!"b#us!ing met!od Manual* soft 'ac5 and fo#t! 2 x pe# da$ &oot!paste %#est 3D 6!itening 3loss None Po6e# Assisted Appliances None Rinses !ate7e# !is 6ife bu$s Sometimes 3luo#ide &oot!paste 2 x pe# da$ 8t!e# None Medical!ental History Summary" 11 #dentify any medical pro$lems that the patient mi%ht ha&e' A#t!#itis* #!eumatoid a#t!#itis* osteopo#osis* fib#om$algia* and !e is cu##entl$ unde# t!e ca#e of a p!$sician because in 2)1) !e !ad su#ge#$ to #emo7e bone cance# in !is #ig!t !ip1 21 #dentify any medical pro$lems that mi%ht complicate dental treatment( and )hat steps should $e ta*en to minimi+e or a&oid their occurrence' 3ib#om$algia: allo6 patient to sit up#ig!t fo# 3-( min befo#e standing to a7oid di44iness1 Ma$ need to limit c!ai# time in t!e supine position based on !o6 6ell t!e patient can tole#ate t!at position1 R!eumatoid a#t!#itis: %onside# semisupine position and limit time in t!e c!ai#1 31 ,ist any aller%ies that the patient has reported' Patient is alle#gic to penicillin* ceclo#* and #emacade1 All cause #espi#ato#$ dist#ess and a #as! in t!e patient1 41 ,ist medications currently ta*en $y the patient and the dental implications of each' None (1 !oes the patient smo*e or use to$acco products- 9es1 !ocument frequency and type of to$acco products used' Patient dips and uses 1 can pe# da$1 :e !as been dipping fo# 1) $ea#s1 -1 .hen )as the patient/s last dental &isit- .hat treatment )as rendered at this appointment- /ast dental 7isit 6as on 2-13-14 fo# a sc#eening and an 3M;1 Patient also #ecentl$ !ad an uppe# pa#tial made on 1-1<-141 <1 .hat is the chief complaint of the patient- (Listed on M/D History) &eet! cleaning and x-#a$s1 =1 ,ist any other medical information that you feel is pertinent to the treatment of this patient' Patient does not cu##entl$ ta5e an$ medications fo# !is a#t!#itis* #!eumatoid a#t!#itis* o# !is fib#om$algia 6!ic! ma$ limit !is abilit$ to tole#ate !o6 long !e can la$ in t!e c!ai#1 ,1 ,ist any other dental information that you feel is pertinent to the treatment of this patient' Patient !as ne7e# !ad !is teet! p#ofessionall$ cleaned befo#e1 :e also seemed some6!at inte#ested in smo5ing cessation1 1)1 Assess the patient/s current le&el of learnin% and state rationale' Must be record in progress notes at every appointment. /ea#ning /e7el: >na6a#e1 Patient is una6a#e about !is pe#iodontal disease o# !o6 dipping effects !is o#al !ealt!1 :e is also not a6a#e about tilting t!e toot!b#us! at a 4( deg#ee angle to clean into t!e sulcus and !e does not floss1 111 /ist all positi7e findings f#om $ou# data collection on t!e Chart of Positi&e Findin%s' 121 >se t!e positi7e findings to fill out t!e Chart of Patient 0eeds1 131 3o# e7e#$ p#oblem listed on t!e %!a#t of Patient Needs* state t!e lon% term %oals fo# dental !$giene t#eatment t!at !a7e been establis!ed b$ t!e clinician and t!e patient1 >nde# eac! long te#m goal* state at least 2 short term %oals t!at 6ill !elp t!e patient attain t!e long te#m goals1 141 State the clinician/s assessment of the possi$ility of the patient/s %oal attainment' (Ex. excellent, good, fair, guarded, poor). Explain your answer. (Consider life-styles, financial ability, social/cultural background, etc.) ? belie7e t!e#e is a fai# c!ance t!at @@@@@@ 6ill ac!ie7e !is goals because !e seems 7e#$ inte#ested in t!e ad7ice t!at ?A7e al#ead$ gi7en !im about !is o#al !ealt!1 :e !as 0uite a bit of o#al !$giene modification a!ead of !im and se7e#al ca7ities t!at need to be filled* but ? belie7e 6it! t!e #ig!t info#mation and positi7e encou#agement* t!at a mode#ate amount of pe#manent be!a7io#al modification 6ill be ac!ie7able1 1(1 Outline t!e info#mation to be p#esented in t!e t!#ee Patient 1ducation Sessions' ?nclude t!e specific info#mation t!at 6ill be taug!t* t!e met!ods of p#esentation* and 6!at 7isual aids 6ill be used1 Submit on a sepa#ate page1 1-1 2eferrals" DDS fo# ca#ies1 1<1 2ecall Schedule" Since patient uses tobacco and !as pe#iodontitis* !is #ecall s!ould be 3-4 mont!s1 11' Chart of Positi&e Findin%s Med!ent History /ast p!$sical in 2))( Pt !as #!eumatoid a#t!#itis Pt doesnAt feel good about !is teet! Pt !as !ad su#ge#$ Pt !as fib#om$algia &eet! a#e sensiti7e all t!e time Pt !as osteopo#osis Pt is alle#gic to penicillin* %eclo#* Remacade %lenc!es !is teet! Pt !ad pel7ic bone cance# >ses dip tobacco dail$ B1) $ea#sC :as an uppe# pa#tial Pt !as a#t!#itis +ums bleed 6!en flossing D#in5s 1 D#1 Peppe# a da$ #ntra13tra Oral 13am P!$s1 /imitations B!ad cance# cut out of #ig!t !ip boneC 8#al /ic!en planus Scatte#ed ep!elids /ingual to#i Ne7i D inc! left of #ig!t e$e Do#sal su#face of tongue pla0ue coated 'od$ t$pe Bp$5nicC Mout! b#eat!s Boccasionall$C Red tonsils and pilla#s &ongue t!#ust :ig! 7ault %#oss bite BE12 6"E2)C BE13 end to end 6"E21C &!ic5ened buccal mucosa Bc!ee5 bitingC %lenc!es 4in%i&alPeriodontal Assessment Mode#ate gene#ali4ed biofilm Pe#io1 %ase 2 'iofilm #etenti7e featu#es: calculus* ca#ies* p#ost!esis +en1 Ma#ginal and papilla#$ inflammation P#edisposing facto#s: mout! b#eat!ing* tobacco +en1 #ed* smoot! and s!in$* bulbous papillae Slig!t gen1 #ed* smoot! and s!in$* #olled ma#gins Recession EAs 2)*21*22*2=*2, 'leeding upon p#obing gen1 max1 and mand1 poste#io# !ental Chartin% Missing : EAs 1*4*=*1(*1-*1,*3)*31 4-< mm poc5et dept!s Att#ition lo6e# ante#io#s %a#ies: EAs 2*3*<*,*1)*12*14*1<*1=*2)*32 Recession: EAs 2)*21*22*2=*2, BfacialC 'leeding gene#ali4ed max1 and mand1 post1 2adio%raphs Mild !o#i4ontal bone loss EAs 2="2, and E= a#ea Mild 7e#tical bone loss EAs 1<"1= %a#ies: >A*>/*//* and /A Missing EAs 1*4*=*1(*1-*1,*3)*31 Other Findin%s 12' Chart of Patient 0eeds Pro$lem 1tiolo%y Positi&e findin%s that correlate )ith the pro$lem5 Contri$utin% or predisposin% factors Patient 1ducation Topics Treatment Options and Pre&enti&e Therapies P#io#it$ E1 Pla0ue
'acte#ia and poo# o#al !$giene -Pla0ue sco#e: 21-2 -Mod1 gen1 pla0ue -Mout! b#eat!ing -&obacco -#ed* bulbous papillae -#olled* #ed gingi7a -%alculus -Pt doesnAt floss -Pt b#us!es using a bac5 and fo#t! motion but doesnAt tilt t!e b#istles at a 4( deg#ee angle to clean into t!e sulcus LTG &!e pt 6ill #educe pla0ue sco#e b$ 1( at e7e#$ appt1 until !e #eac!es 11121 !TG " Pt 6ill desc#ibe pla0ue fo#mation b$ t!e second appt1 !TG # Pt 6ill co##ectl$ use t!e 'ass b#us!ing tec!ni0ue b$ t!e t!i#d appt1 -Soft deposit #emo7al -%alculus #emo7al -Fncou#age p#ope# !ome ca#e on a dail$ basis -Antibacte#ial mout!6as! -Patient education P#io#it$ E2 Pe#iodontitis 'acte#ia -Mode#ate gene#ali4ed biofilm -+ene#ali4ed #ed* bulbous papillae - Slig!t gene#ali4ed #ed* #olled ma#gins - Mild !o#i4ontal bone loss EGs 2="2, and E= a#ea - Mild 7e#tical bond loss EAs 1<"1=1 - Mout! b#eat!ing -&obacco use -Pt doesnAt floss -Pt b#us!es using a bac5 and fo#t! motion but doesnAt tilt t!e b#istles at a 4( deg#ee angle to clean into t!e sulcus LTG &!e pt 6ill unde#stand 6!at pe#iodontitis is and !o6 to !alt t!e p#og#ession of !is pe#iodontal disease1 !TG " Pt 6ill be able to desc#ibe 6!at pe#iodontitis is b$ t!e second appt1 !TG # Pt 6ill be able to demonst#ate p#ope# H%G s!ape flossing b$ t!e t!i#d appt1 and c!oose to floss e7e#$ ot!e# da$ b$ 4-=-141 !TG $ Pt 6ill c!oose to floss e7e#$da$ b$ 4-22-141 -Pe#iodontal deb#idement -Regula# 3-4 mont! #ecall -P#ope# !ome ca#e maintenance -Antibacte#ial mout!6as! P#io#it$ E3 %a#ies I 3luo#ide
'acte#ia* poo# o#al !$giene -Radiog#ap!s s!o6 suspicious a#eas -%a#ies can be seen clinicall$ in t!e mout! -Pla0ue sco#e: 21-2 -%alculus -?##egula# dental c!ec5-ups -Pt doesnAt floss -Poo# o#al !$giene LTG &!e pt 6ill be able to explain 6!at ca#ies is* !o6 ca#ies a#e fo#med* and !o6 fluo#ide !elps #educe t!e #is5 of ca#ies1 !TG " Pt 6ill be able to explain 6!at causes ca#ies and !o6 ca#ies a#e fo#med1 !TG # Pt 6ill be able to explain !o6 fluo#ide #educes ca#ies1 -At !ome fluo#ide #inses -Refe# to DDS fo# ca#ies -P#ope# !ome ca#e maintenance -P#ofessional in office fluo#ide t#eatments Patient 1ducation Sessions 11 Patient Fducation &opic E1: Pla0ue Long Ter% Goal &!e pt 6ill #educe pla0ue sco#e b$ 1( at e7e#$ appt1 until !e #eac!es 11121 !TG " Pt 6ill desc#ibe pla0ue fo#mation b$ t!e second appt1 !TG # Pt 6ill co##ectl$ use t!e 'ass b#us!ing tec!ni0ue b$ t!e t!i#d appt1 ?1 !at is pla0ueJ Pla0ue is a stic5$* basicall$ colo#less film of bacte#ia and food pa#ticles t!at fo#m on t!e teet!1 Pla0ue is t!e main cause of gum disease1 ?t can !a#den into calculus Bta#ta#C if not #emo7ed p#ope#l$ eac! da$1 'acte#ia use t!e suga# found in t!e sali7a and pla0ue to feed on1 &!e bacte#ia p#oduce acid as a b$p#oduct 6!en t!e$ eat t!e pla0ue1 &!e acid attac5s ou# teet! and sta#ts t!e ca#ies p#ocess* 6!ic! in time can fo#m a ca7it$ on t!e toot!1 ??1 ill s!o6 patient !is pla0ue sco#e at e7e#$ appointment to !opefull$ ma#5 its decline 6it! e7e#$ appointment as stated in !is goals1 ? 6ill also explain t!e scale 6e base ou# pla0ue sco#e on as 6ell as s!o6 !im 6!e#e t!e pin5 and pu#ple a#eas a#e* and explain t!e diffe#ence in colo#1 Pin5 is less t!an 24 !ou#s old and pu#ple is olde# t!an 24 !ou#s old1 ???1 P#ope# b#us!ing1 Discuss !o6 !is b#us!ing tec!ni0ue is not #eac!ing into t!e sulcus to clean off t!e pla0ue effecti7el$1 Fxplain t!e 'ass met!od of b#us!ing and !o6 using t!is met!od is effecti7e at #eac!ing into t!e sulcus 6!en t!e b#istles a#e positioned p#ope#l$ at a 4( deg#ee angle1 ?nst#uct patient on !o6 to position t!e b#istles at a 4( deg#ee angle into t!e a#ea bet6een t!e teet! and gums1 Ad7ise patient to t#$ and b#us! 2-3 teet! in a 7ib#ato#$* !o#i4ontal motion and to b#us! fo# a full 2 minutes at least t6ice dail$1 ill demonst#ate b#us!ing on a t$podont1 Allo6 patient to demonst#ate on t$podont and t!en at t!e sin51 21 Patient Fducation &opic E2: Pe#iodontitis
Long Ter% Goal&!e pt 6ill unde#stand 6!at pe#iodontitis is and !o6 to !alt t!e p#og#ession of !is pe#iodontal disease1 !TG " Pt 6ill be able to desc#ibe 6!at pe#iodontitis is b$ t!e second appt1 !TG # Pt 6ill be able to demonst#ate p#ope# H%G s!ape flossing b$ t!e t!i#d appt1 and c!oose to floss e7e#$ ot!e# da$ b$ 4- =-141 !TG $ Pt 6ill c!oose to floss e7e#$da$ b$ 4-22-141 ?1 !at is pe#iodontitisJ !en gum disease ad7ances be$ond t!e soft tissue into t!e bone* it is called pe#iodontitis1 &!is disease is i##e7e#sible* 6!ic! means t!at $ou# bod$ cannot #efo#m o# #eg#o6 t!e tissues and bone t!at $ouA7e lost* but $ou can !alt t!e p#og#ession of t!e disease1 &obacco use* genetics* and poo# o#al !$giene can ma5e $ou mo#e susceptible to pe#iodontal disease1 ??1 ill s!o6 patient 7isual aids of !ealt!$ pin5 gum tissue and #ed* inflamed* infected tissue1 ???1 P#ope# flossing1 ?t is #ecommended t!at $ou floss at least once a da$1 &a5e about 1= inc!es of floss and 6ind it a#ound $ou# middle finge#s* lea7ing about 2 inc!es fo# $ou# index finge#s and t!umbs to 6o#5 6it!1 >se $ou# index finge#s and t!umbs to guide t!e floss bet6een t!e teet!1 3o#m a H%G s!ape 6it! t!e floss against eac! toot!1 Mo7e t!e floss up and do6n a couple times to ma5e su#e $ou get all t!e pa#ticles loose1 +entl$ #emo7e t!e floss f#om t!ose teet! and mo7e on to t!e next space1 >se $ou# middle finge#s as t!e spool t!e floss is on and 6ind it a6a$ f#om $ou to get a ne6 piece of floss fo# eac! ne6 space1 Ma5e su#e to floss be!ind t!e last teet!1 ?K1 ill demonst#ate p#ope# flossing on t$podont1 ill !a7e patient demonst#ate p#ope# flossing on t$podont1
31 Patient Fducation &opic E3: %a#ies and 3luo#ide Long Ter% Goal &!e pt 6ill be able to explain 6!at ca#ies is* !o6 ca#ies a#e fo#med* and !o6 fluo#ide !elps #educe t!e #is5 of ca#ies1 !TG " Pt 6ill be able to explain 6!at causes ca#ies and !o6 ca#ies a#e fo#med1 S&+ 2: Pt 6ill be able to explain !o6 fluo#ide #educes ca#ies1 ?1 !at is ca#iesJ %a#ies is anot!e# name fo# ca7ities1 %a#ies a#e fo#med b$ t!e bacte#ia in ou# mout!s feeding off of t!e suga# t!at 6e consume and t!e #esult is an acid b$p#oduct t!at attac5s and b#ea5s do6n t!e enamel on ou# teet!1 &!e acid attac5s cause demine#ali4ation of t!e enamel1 8nce t!e deca$ b#ea5s t!#oug! t!e enamel* a ca7it$ is fo#med1 A dentist must t!en clean out all t!e deca$ and fill t!e toot!1 ?f left unt#eated* t!e deca$ can dest#o$ a toot! all t!e 6a$ do6n to t!e ne#7e1 S!o6 patient 7isual aid of a ca7it$ and use !is #adiog#ap!s to s!o6 !im 6!e#e !is a#e1 ??1 3luo#ide ?nst#uction
3luo#ide is found in man$ !ome ca#e aids and can also be applied as pa#t of $ou# dental t#eatment1 ?t !elps st#engt!en $ou# enamel* ma5ing it mo#e #esistant to acid attac5s* and aids in t!e #emine#ali4ation p#ocess1 %#est P#o-:ealt! is an 8&% mout!6as! t!at !as fluo#ide in it1 S!o6 patient a sample of a mout! #inse 6it! fluo#ide in it and 6!e#e to find it on t!e label1