Patient Name: ****** Age __57_____

Date of initial exam_10/7/2014_____________________ Date completed : 11/23/14

1. Medical History: (systemic conditions altering treatment, pre-medication, medical clearance) explain steps to
be taken to minimize or avoid occurrence, effect on dental hygiene diagnosis and/or care.
My patient is not under the care of a physician as of now. She has a dentist but cannot return due to financial
issues. Patients last physical was 3 months ago (July 2014). She is on no medications. Patient has had a few
surgeries; tonsillectomy around 45 years ago, cesareans sections around 35 and 40 years ago, had a dental
implant placed one year ago, removal of kidney stones two years ago, and nodules on throat removed 30 years
ago. She is unsure is she has osteoporosis. Patient stated that she has deterioration of the back. She has no
cardiovascular disturbances. She is allergic to nothing, and she does not smoke or drink. Her vital signs were
WNL on first appointment (screening) other than her regularly irregular pulse. At her second appointment, her
blood pressure was 140/90 Stage 2 hypertension and 140/95 Stage 2 hypertension for the third appointment. I
asked her about this each time. The first time she said she hadnt drank any coffee like she normally does, yet the
second and third appointment she said she had a large cup of coffee that morning.
Steps to be taken include: recommending a doctor appointment to be checked for osteoporosis especially
considering her age, ask the doctor about her blood pressure since it was Stage 2 hypertension for her second and
third appointment, allow her to sit up often due to the deterioration of her back, and recommended decreasing the
amount of coffee she drinks.
2. Dental History: (past dental disease, response to treatment, attitudes, dental I.Q., chief complaint, present oral
hygiene habits, effect on dental hygiene diagnosis and/or care)
Patients chief complaint was for a cleaning and x-rays. Her last dental visit was one year ago and it was for a
cleaning and placement of dental implant. She states she has had no serious problems associated with dental
treatment. She feels good about her appearance of her teeth/smile. She was unsure about the last time she had any
x-rays taken. Her gums bleed when she brushes and flosses sometimes, but not often. Her teeth feel sensitive to
hot, cold, and sweets sometimes. Patient does not clench teeth, but grinds teeth sometimes when sleeping. Patient
states she sometimes has many cavities when has dental checkup. She drinks one sugar containing drink a day,
and chews sugarless gum. Patient has VERY positive and interested attitude. Her learning level is Self-Aware,
because she asks many questions and really wants to learn! Overall patient has good nutrition habits.
Steps to be taken include: Taking a Full Mouth X-ray, Patient Education on importance of routine dental visits,
brushing, flossing, grinding of her teeth, and caries process.

3. Oral Examination: (lesions noted, facial form, habits and awareness, consultation)
Extraoral: Patient has one raised nevi behind ala of nose on the right side of the face. It is 5mm, brown,
round, solid, and has a well-defined border. The etiology is developmental. She also has scattered
ephelides on face that are 1mm, brown, and flat. The etiology is developmental. Patient has 2mm brown
nevi on right side of the chin line. It is raised and well-defined. The etiology is developmental.
Intraoral: Patient has had tonsillectomy. The etiology is surgery. For labial mucosa, the patient has
mandibular anterior bite marks due to lip biting. The etiology is trauma. For buccal mucosa, the patient
has bilateral linea alba and the etiology is lip biting/trauma. The patient has a plaque-coated tongue and
the etiology is bacteria.
Patient grinds her teeth sometimes at night. She also clenches sometimes throughout the day. Patient
tongue thrusts when swallowing. Patients occlusal examination consists of Class 1 all around, she has a
4mm overbite, 3mm overjet, and no mid-line shift. Patient has a cross-bite involving only tooth number
three. Her teeth are straight for the most part other than her mandibular anterior.
4. Periodontal Examination: (color, contour, texture, consistency, etc.)
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a.Case Classification: 6
b. Periodontal Case Type: 3
b. Gingival Description:
App't 1:
Patient has a generalized scalloped architecture, the color of her gingiva is red on the anterior
mandibular lingual/facial and whitened on the maxillary anterior facial. Consistency is
generalized edematous. Margins are generalized rolled. Papillae are bulbous on the
mandibular anterior lingual and facial, but blunted between teeth 8-10. There was no
suppuration. Surface texture was generalized smooth and shiny.
App't 2:
Gingival statement is the same as first appointment. Cleaning has not begun yet.
App't 3:
Gingival statement is still the same as the first appointment. Cleaning has not begun yet.
Periodontal assessment was just completed today which was very difficult due to her deep pocket
depths and buildup of subgingival calculus.
App't 4:
I just began debridement this appointment; therefore, there have been no changes yet. I began
use of the ultrasonic on her mandibular right quadrant.
App't 5:
Not much has changed since I had to go back and fine scale. She said her gums feel sore which
I expected considering the fact that she has very deep pockets and would not let local
anesthesia be administered to her. I finished fine scaling the mandibular right and I finished
use of the ultrasonic on the maxillary right quadrant.
App't 6:
I can definitely tell a difference now in her gingival tissue on the mandibular right. It is not as
red, edematous, or rolled in this quadrant now that it has had some time to heal. Today I finished
fine scaling the maxillary right.
Appt 7:
The mandibular right quadrant looks like much healthier and tighter tissue, and the maxillary
right is slowing looking better. It is not quite as red or rolled today. Today I finished using the
ultrasonic on the maxillary left and started fine scaling.
Appt 8:
The maxillary right quadrant definitely looks much healthier. It is not red, edematous, or
rolled. I finished fine scaling the maxillary left and finished use of the ultrasonic on the
mandibular left (last quadrant).
Appt 9:
I finished fine scaling the mandibular left quadrant. All of the quadrants besides the
mandibular left quadrant are looking so much healthier. The tissues are tighter in certain areas
but somewhat looser in other areas. This is due to having an extensive amount of calculus cleaned
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out from those certain pockets. It will take a little longer for those pockets to tighten up. They
were pinker, like they are supposed to be. Her bleeding score has gone down to 2%!
Appt 10:
All of her gingiva is looking very healthy! Her bleeding score has gone down to 1.1%. This
appointment I applied the antibiotic, Arestin to 8 different deep pockets.
c. Plaque Index: Appt 1: 0.8 good
2: 1.3 good
3: 1.3 good
4: 1 good
5: 0.6 good
6: 1.2 good
7: 0.5 good
8: 0.1 good
9: 0.3 good
d.Gingival Index: Initial: 1.04

Final 0.04

b. Bleeding Index: Appt 1: not taken

2: 13%
3: 2.8%
4: not taken
5: not taken
6: not taken
7: 7.2%
8: 2%
9: 1.1%
f. Evaluation of Indices:
1. Initial
Her initial plaque score was 0.8 which is good. I was not expecting this since she had so much buildup.
Most of her supragingival buildup was interproximally in the posterior and interproximally in the
mandibular anteriors facial and lingual (most likely due to malpositioned teeth). Her gingival index was
13% which is fair. Her bleeding score is 13%.
1. Final
Her plaque and bleeding score both improved! Her plaque score went from 0.8 to 0.3 which is good.
Her bleeding score went from 13% to 1.1%. The gingival index even changed from 1.04 fair to 0.04
good. She is brushing 2-3x day and flossing at least once a day now. She DID have a little bit of
calculus buildup on the mandibular anterior teeth that I had to remove at the last appointment, so I told
her to make sure she is especially brushing and flossing good right there since she had quicker buildup
in this area.
g.Periodontal Chart: (Record Baseline and First Re-evaluation data)
1.Baseline
I was able to get the pocket depth, tissue height, and CAL. She was originally screened to be a class 4 but
was changed to a class 6 due to how difficult she was. In the maxillary facial and lingual, the pocket
depths ran from 1-8mm. She had spots of recession on the maxillary facial #s 5, 6, 9,11,12,13, and 14.
On the maxillary lingual, she had recession on #s 4 and 7. She has furcation on tooth number 14 but not
clinically. CAL on the facial maxillary ranged from 1-6mm with tooth #14 having a 6mm distal (facial

and lingual). CAL on the lingual was 6mm on 14distal and 13 distal. Patient had tooth mobility of 1 on
teeth 8-10.
On the mandibular lingual, pocket depths ranged from 1-8mm with 8mm being on tooth #17. On the
mandibular lingual, CAL ranged from 1-5mm. There was lingual recession on #s 19, 20, and 22-27. On
the mandibular facial, pocket depths ranged from 2-7mm with the highest being 7mm on #30distal. She
has facial recession on #s 18-26, and 28. CAL on the mandibular facial ranged from 1-7mm. Tooth
#26mesial had the 7mm. She had mobility of 1 on teeth 23-26.

1. First Re-evaluation
In the maxillary arch (facial/buccal side), her pocket depths ranged from 1-9mm; 9 mm being on number
16mb. The tissue height ranged from 1-4mm. The CAL ranged from 1-6mm. On the lingual side, the
pocket depths ranged from 1-8mm. The tissue height ranged from 0-4 and the CAL ranged from 0-5mm.
There were few areas of recession. On the mandibular arch (facial/buccal side), her pocket depths ranged
from 1-7mm. The tissue height was from 0-4 with multiple areas of recession. The CAL ranged from 07mm. On the lingual, the pocket depth ranged from 1-8mm. The tissue height was from 1-4mm with
multiple areas of recession and the CAL ranged from 1-5mm.
1.Dental Examination: (caries, attrition, midline position, mal-relation of groups of teeth, occlusion,
abfractions)
Caries: #3 distal facial (Caries affect the periodontium because it harbors bacteria and allows it to
mature, and as it matures, the bacteria change from gram positive to negative, which are the bacteria
that cause periodontitis. Therefore caries can increase the risk of periodontitis.)
Watch areas: #18 distal occlusal (recurrent)
Attrition: #6, 8-11, 24, and 25 (Grinding of the teeth will affect the periodontium because it puts forces
on the periodontium which causes trauma and possible progression/advancement.)
Mid-line position: none
Mal-relation: #3 crossbite, #22 distoverted, #24 labioverted, and #30 buccoverted. (Malpositioned teeth
allow plaque to adhere, that leads to calculus, which ultimately affects the periodontium as noted in
number 7.)
Occlusion: Case 1 on all areas
Amalgam restorations: #15 D-O
Tooth colored restorations: #18 distal
Dental Implant: #19 with Zirconium crown
Missing teeth: #1 and 32
** I will educate the patient on her dental implant to floss and brush like normal, but do not use proxy
brush or anything metal around the implant. It is important to also keep it clean because plaque and
calculus will still adhere to her zirconium crown.

6. Treatment Plan: (Include assessment of patient needs and education plan)

App't 1:
Reviewed Medical Dental History (from screening), pre-rinse, Full mouth x-rays were taken for
detection of caries on an off clinic day, plaque score, was taken, finished Intra/extraoral exam but
did not get checked, finished dental charting but did not get checked, started full Periodontal
Assessment but did not finish Mandibular left lingual (everything else for periodontal assessment
was checked), and chairside patient education on brushing, flossing, gingivitis, and
causes/prevention. Also, 0.4ml of Cetacaine was used on all quadrants.
App't 2:
Reviewed medical dental history, pre-rinsed, plaque score, bleeding score, and gingival index was
taken, got intra/extraoral exam checked along with dental charting with x-rays and periodontal
assessment for the mandibular left lingual. Use of 0.4ml of Cetacaine was used on the mandibular
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left lingual quadrant. I finished the risk assessment and informed consent. I did the first patient
education session over plaque and brushing, went over all long-term and short-term goals. Patient
will need local anesthesia for next appointment for when I scale.
App't 3:
Review medical dental history, pre-rinse, plaque score, bleeding score, do patient education
session 2 over periodontitis and flossing, get dentist to administer local anesthesia, and begin use
of ultrasonic and fine scale one quadrant.
App't 4:
Review medical dental history, pre-rinse, take plaque score and bleeding score, do patient
education session 3 over Caries and fluoride/sealants. I will get the dentist to administer local
anesthesia, then ultrasonic second quadrant and fine scale.
App't 5:
Review medical dental history, pre-rinse, take plaque score and bleeding score. I will ask the
dentist to administer local anesthesia, then begin use of ultrasonic on third quadrant and then
fine scale. I will also be doing chairside patient education over all 3 sessions.
App't 6:
Review medical dental history, pre-rinse, take plaque score and bleeding score. I will ask the
dentist to administer local anesthesia, then begin use of ultrasonic on last quadrant and then fine
scale. I will review all patient education topics of plaque, brushing, periodontitis, flossing, the
caries process and fluoride/sealants. I will recommend the use of a proxy brush also. Next I will do
plaque free (flossing and polishing), then sealants on #s 20, 21, 28, and 29. Lastly, I will apply
fluoride varnish and give post instructions.
App't 7:
This appointment will be done 2 weeks after the last quadrant is scaled. I will review the medical
dental history, pre-rinse, take plaque score and bleeding score, then do full periodontal charting,
calculus evaluation, Arestin treatment. I will take intraoral pictures to show her the before and
after results. Then I will discuss with her the importance of regular dental visits and I will assist
her in making an appointment to get a cavity fixed. I will refer her to a periodontist and set up a
recall appointment in 3 months (February 21st,2015).
7. Radiographic Findings: (crown root ratio, root form, condition of interproximal bony crests,
thickened lamina dura, calculus, and root resorption)
I found mild horizontal bone loss in the upper right and upper left posterior generalized. I found
moderate horizontal bone loss in the upper anterior and lower anterior generalized. I found
moderate vertical bone loss on #31 mesial and #19 mesial/distal. Calculus was found on upper
right, upper left, and lower anterior (generalized anterior mandibular); also #14 distal, 15
mesial/distal, 16 mesial, and 3 mesial/distal. Caries were found on #3 distal, and a Watch on
#18 distal (possibly recurrent). Patient has been classified as a Periodontal Case 3.

8. Journal Notes: (Record in detail the treatment provided, oral hygiene education, patient response,
complications, improvements, diet recommendations, learning level, short and long term goals, expectations,
etc.) The progress notes should be written by appointment date.

*10/7/14: Today I reviewed the medical/dental history, let the patient pre-rinse, and then I took a
digital full mouth radiograph series on her. This was taken for caries detection. Next I took her
plaque score which started off at 0.8 (good). Patient was very sweet and interested. I used 0.4ml of
Cetacaine throughout the mouth where she was sensitive (which was almost everywhere, so I had to
distribute it accordingly). I finished the head and neck extraoral exam. I finished dental charting
with x-rays, but these were not checked today. I started the periodontal assessment but only got
through 3 quadrants. She was especially hard to work on because her pocket depths were high and
she was extremely sensitive and complained a lot about that. I had to keep stopping. She did not
want local anesthesia. Learning level was unaware.
*10/9/14: Patient came in for me during my outside clinic time so that I could just take 2 x-ray
retakes that I needed. I reviewed the medical/dental history and let her pre-rinse and then took the 2
x-rays.
*10/10/14: I reviewed the medical/dental history and let her pre-rinse. Next I took her plaque score
which was 1.3 (good) and bleeding score which was 13%. I immediately got the Head and neck
extraoral exam checked along with dental charting with x-rays. I took the gingival index which was
1.04. Today I finished probing the mandibular left quadrant and got my periodontal assessment
checked. I used 0.4ml Cetacaine on this quadrant due to sensitivity and all of her complaints. I
finalized the informed consent and risk assessment. I did the first patient education session on her
which was over plaque and brushing. Patient Long Term goals included: maintaining a plaque score
of 0 by the last appointment, halt the progression of periodontitis by the last appointment, and to
have her cavities restored in the next 6 months recall. Short terms goals included were: patient will
describe plaque and how it forms by the second appointment and patient will learn the modified
bass technique and demonstrate on the typodont by the next appointment. Secondly, patient will
describe what periodontitis is and will demonstrate flossing on typodont by the following
appointment, and patient will have a decreased bleeding score. Third, the patient will learn and
describe caries process by the last appointment, patient will make an appointment with DDS to get
caries restored, and we will discuss sealants and fluoride treatment options. For the 3rd session, my
patient assessment was guarded. Learning level was unaware.
*10/14/14: I reviewed the medical/dental history and let patient pre-rinse. I took a plaque score
(1.3good) and bleeding score (2.8%). Today I did patient education session 2 over periodontitis and
flossing. I reviewed plaque and brushing on the typodont also. I was able to talk to the patient into at
least trying the local anesthesia. So the dentist came by and administered Ceptacaine with
epinephrine on the mandibular right quadrant. Like Ive mentioned before, her pocket depths were
high and she even complained with having the local anesthetic. I was able to ultrasonic the
mandibular right quadrant and that was it. At this point, her learning level is now aware. She is
AWARE that there is a problem and that she has periodontitis.
*10/21/14: I reviewed the medical/dental history and let the patient pre-rinse. I took only the plaque
score which was 1 (good). She would not let us use the local anesthesia on her again because she
feared getting a shot. She said that is not why she doesnt want it, but I can tell that that IS why. I
tried urging her into changing her mind about it because it would really help and make her feel more
at ease, but there was nothing I could say or the dentist or the instructor that would make her change
her mind. Today was especially hard because I was finally really getting into the cleaning part, and
yet I had to keep stopping because she would constantly complain. There wasnt much I could do
other than give her the Cetacaine and I could give her no more than 0.4ml. I fine scaled her
mandibular right quadrant and then finished with use of the ultrasonic on the maxillary right
quadrant. With all the stops I had to make for her, I was not able to begin fine scaling today.
*10/28/14: I reviewed her medical/dental history. There were no changes. I let her pre-rinse then I
took her plaque score only which was 0.6 (good). She was doing very good with using the
recommended technique and told me she was flossing every day at this point. She is a very sweet
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patient and has been early to every one of her appointments so far which I highly appreciate. I used
0.4ml of Cetacaine and finished scaling the maxillary right quadrant. Then, I started use of the
ultrasonic on the maxillary left quadrant. I reviewed plaque, brushing, and flossing chairside.
*10/31/14: I reviewed her medical/dental history and let her pre-rinse. I took a plaque score only
which was 1.2 (good). I got the maxillary right quadrant checked off and finished using the
ultrasonic on the maxillary left quadrant. I reviewed plaque, brushing, flossing, and bleeding.
Learning level is aware.
*11/7/14: I reviewed the medical/dental history and let her pre-rinse. I took her plaque score which
was 0.5 (good) and bleeding score which was 7.2%. I used Cetacaine (0.4ml) on the maxillary left
and mandibular left. I finished fine scaling the maxillary left quadrant, then I was able to ultrasonic
the mandibular left quadrant. It was hard to get a lot done even in 2 hours because of the extent of
the calculus and how deep her pockets were. I instructed her about proper care of her dental implant.
Her learning level for today was aware.
*11/11/14: I reviewed the medical/dental history and let her pre-rinse. I took her plaque score which
was 0.1 (good) and bleeding score was 2%. I used 0.4ml Cetacaine on the mandibular left quadrant.
I finished fine scaling the mandibular left quadrant. I did plaque free which consisted of polishing
and flossing. Next, I did sealants on numbers 20, 21, 28, and 29. Lastly, I applied fluoride varnish to
her teeth and gave her post instructions. Chairside education consisted of plaque, brushing, flossing,
caries, and fluoride. Learning level is aware.
*11/21/14: I reviewed the medical/dental history and let her pre-rinse. Then I took her plaque score
which was 0.3 (good) and bleeding score which was 1.1%. Next, I did patient education session 3
over the caries process, fluoride, and sealants. I referred her to a periodontist and gave her a recall
appointment of 3 months which will be February 21, 2015. Lastly I did post periodontal evaluation
and post calculus evaluation. There was just a little bit of calculus on her mandibular anterior
lingual that I removed easily. I applied the antibiotic Arestin to numbers 3mf, 4df, 12df, 14df, 16m,
17df, 17ml, and 21db. Her learning level is still aware. Before letting her leave, we discussed
nutrition a little more. I recommended cutting back on the coffee and teas since she had a lot of
staining. She had also told me before that she liked sucking on hard candies, so after our patient
education session today, she understood better why diet is also an important factor in keeping her
teeth healthy.

9. Prognosis: (Based on attitude, age, number of teeth, systemic background, malocclusion, tooth morphology,
periodontal examination, recare availability)

My patient had a great attitude about receiving treatment. Although she was very sensitive and I could
tell it made her nervous, she was still punctual and never missed an appointment. She was determined
as much as I was to get all the treatment completed. The patient is 57, has 30 teeth, and the only
systemic background she has is osteoporosis. She said she has deterioration of the back. She has a
crossbite that only includes tooth number 3 and tooth number 30 is buccoverted. She had no tooth
morphology. She was not very educated about dental hygiene when we first started but after chairside
education and patient education in the side room, she has learned a lot and is already flossing more and
applying the proper brushing technique daily. She wanted to know her recall date immediately because
she said she would definitely be back. She now understands how to halt the progression of the disease
and knows how to properly have good oral hygiene!
10. Supportive Therapy: Suggestions to patient regarding re-evaluation, referral, and recall schedule. (Note:

Include date of recall appointment below.)

The patients recall date is February 21, 2015. I referred her to the DDS to get restorative dentistry done
on the distal of number 3. I also referred her to a periodontist to get looked at. I know that makes her
very nervous especially because she clearly doesnt like shots, but she severely needs to go because of
her deep pocket depths. Ive recommended using a proxy brush to help clean in between the teeth or
just to use regular floss like I showed her. I recommended using mouth rinse at least 1 time a day, and
getting a mouth guard to help prevent any more damage from clenching and grinding.
11. Assessment of Changes: (including plaque control, bleeding tendency, gingival health, probing depths)

The patients plaque control differentiated. It wasnt very high when she came in, but it was back and
forth throughout appointments, but all in all, it stayed in the good range. As for her bleeding index, it
started off at 13% and went lower from there except for one appointment when it was 7.2%. She had
told me that day that she thinks she was bleeding more because of a sharp chip she ate that hit her gumline. Her ending bleeding index was only 1.1% which is way more improved since it started off so high.
Her gingival index also changed a lot from 1.04 to 0.04! Her gingiva started out as red, scalloped,
edematous, bulbous, blunted, and smooth and shiny. Now her gingiva is much healthier. She has a few
spots of localized redness, but her tissues are not edematous or bulbous anymore. Many of her pocket
depths decreased, but some also increased due to the subgingival calculus buildup that was removed.
The tissue was not completely healed or tightened yet.

12. Patient Attitudes and Cooperation:

My patient complained a lot when it came to sensitivity, which made it hard to finish her in a decent
amount of appointments, but other than that, she was a great patient. She was ALWAYS 30 minutes to
an hour early. She never had to reschedule and if I needed her last minute, she was available. She was
very willing to help me and to also help herself by learning. She did not just come to the appointments
and let the information I told her go in one ear and out the other she listened to my suggestions and
applied them to her oral hygiene.
13. Personal Evaluation/Reaction to Experience:
My experience with my patient was rough overall, BUT I still felt very lucky to have someone so
willing to help me out and to come to every single long appointment. This was definitely an experience
for me and I feel more educated also. I took mental notes of what I can do differently and what I did
well. I feel like I will be faster also now that I know how to do more that I dont typically do on every
patient (such as full periodontal charting). Every appointment was a learning process for me also with
how to talk to my patient and keep her comfortable. Even though it was a stressful process, I look
forward to seeing her again next semester!

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