10. Left nodule 2mm, 1 inch from acoustic meatus etiology: 10. Skin cancer
developmental
12. Cheek bite marks on posterior right and left etiology: 12. Infection
trauma
13. Right molar occlusion unclassifiable 13. Plaque retention, malocclusion, interference with eating
14. Right canine, left canine, and left molar are class III on 14. Malocclusion
occlusion
16. Color: Red on #14 and #15 papilla in margin on facial and 16. Periodontitis
lingual. Whitened and red on upper posterior on left
(tissue sloughing)
19. Shape, papillae: Bolbous #14 & #15 darker red lingual 19. Periodontitis
papillae is swollen
20. Shape, margins: Rolled on #14 & #15 on lingual 20. Periodontitis
21. Position of margin (recession): #28 (2mm) #29 (1mm), 21. Periodontitis
localized 1-2 mm on posteriors
22. Pocket depths are 4’s and 5’s on posterior teeth 22. Periodontitis
24. Mild horizontal bone loss on UR and LL #2, #3,#28, #29 24. Periodontitis, bone loss, increased periodontitis if not
stopped
25. Vertical horizontal bone loss on UL and LL #12, #13, #20, 25. Periodontitis, bone loss, increased periodontitis if not
#21 stopped
27. Calculus UR, UL, LL, LA, LR generalized 27. Periodontitis, decay
Periodontal Case Type: 2 Plaque Score: 3.16 Fair Bleeding Score: 12.5 %
Problem Etiology
1. Plaque ------------------------------------------------------------------- 1. Environmental factors
2. Periodontitis ----------------------------------------------------------- 2. Plaque accumulation
3. Caries -------------------------------------------------------------------- 3. Microbial bacteria
Planned Interventions
Expected Outcomes
STG: Patient will correctly demonstrate proper flossing. Demonstrate proper flossing
technique; Evaluate patients End of treatment
STG: Patient will show improvement in bleeding scores. flossing method; reduce pocket
depths, stop bone loss, bleeding
score
LTG 3: Patient will have her carious lesion restored.
STG: Patient will define caries by end of treatment.
3. Caries/ fluoride
STG: Patient will schedule an appointment with the dentist for 3-4 months by
end of treatment for a cleaning and as soon as possible to treat for caries.
Behavior change (diet/nutrition)
STG: Patient will choose to use home fluoride by the end of treatment. Review methods of brushing, 3 months
rinsing, and flossing
Usage of Fluoride
Appt # Plan for Treatment Plan for Education, Counseling or Oral Hygiene Instruction
Medical/ dental HS 1. Plaque
1 Pre-rinse 2. Brushing
Plaque/bleeding score 3. Flossing
Patient Ed
Scale UL Define Plaque
X Teach proper techniques of brushing
Watch patient brush
Adjust/reeducate brushing if needed
Competency quadrant
X
Medical/ dental HS Evaluate progress, make suggestions. re-educate
Pre-rinse
4 Plaque/bleeding score
Patient Ed X X
Apply Fluoride
Polish all quadrants X X
Scale LL