Special Needs Tx Plan

Kendre Kamm

July 17, 2018

Assessment:

A. Minor sensitivity to cold & sweets occasionally, areas of food impaction on the lower

mandibular teeth #28-29, pt experiences dry mouth due to medications but stated it’s time to

have her teeth cleaned because she can’t do a very good job herself.

B. Patient has had previous extractions of 3rd molars and #15, 18, 31. Pt has 25 teeth total.

Pt frequently has ulcers throughout the mouth from GERD. She seemed happy to be at her

appointment and has no history of bad dental experiences but stated she has had a lot of work

done over the years.

a. Medications:

i.Lovastatin (40 mg) for prevention of coronary artery disease, slow progression of coronary

atherosclerosis; can assess unusual presentations of muscle weakness or myopathy resulting

from lipid therapy.

ii.Omeprazole (40 mg) used for short term tx of erosive esophagitis due to acid-mediated GERD;

can cause taste perversion, xerostomia, esophageal candidiasis, & mucosal atrophy (tongue).

iii.Calcium (600 mg) dietary supplement to prevent calcium deficiency; no dental effects.

iv.Lisinopril (10-12.5 mg) to control high blood pressure; use caution when changing positions

during or after dental tx.

v.Latanoprost (eye drops) used for reduction of elevated intraocular pressure (IOP) in pt’s with

open-angle glaucoma and ocular hypertension; no effects on tx.

vi.Leflunomide (20 mg) for tx of adults with active rheumatoid arthritis; can cause xerostomia,

stomatitis, oral candidiasis, abnormal taste, enlarged salivary glands, esophagitis, and gingivitis.
C. Pt has severe rheumatoid arthritis and her hands are very swollen and painful. She has

a difficult time brushing and flossing her teeth due to immobility of her hands from active RA,

gripping a toothbrush is extremely difficult because of the severely inflamed joints.

D. Pt stated that she has family history of rheumatoid arthritis and remembers her

grandmother and grandfather both were affected by RA. Patient does not smoke or drink.

E. BP: 112/64

F. Extra Oral: wears glasses because of glaucoma,TMD slightly more pressure on left side

and clicking on both sides. Intra oral: single minor lesion on hard palate 1 mm in diameter, (pt

says it has may have been from eating tortilla chips), coating of the tongue, bilateral mandibular

tori, bilateral linea alba, minor chapped lips solar cheilitis. Plaque score: 47%. Perio case type:

GEN Slight, LOC Gingivitis. Calc Class: B. Occlusion: Class 1 R & L

G. Periodontal probing measurements are stable ranging from 2~4 mm. Bleeding on

probing spontaneously.

H. Pt seems to have severe dry mouth & explained that dry mouth is common for her from

her meds. GEN erosion & recession. LOC attrition on lower anteriors. Slight rotation of lower

anteriors.

I. Radiographs on file: CMS from 2016. Visible bone loss present on radiographs and

multiple restorations present.

DH Diagnosis (Problem Identification)

A. Oral health: Fair. Physical health: Fair

B. Gingivitis (visible redness of gums in isolated areas of the mouth, bleeding present)

could be due to multiple medications pt is taking with side effects of increased risk for gingivitis

and poor oral hygiene from RA.

Plan
A. Comprehensive exam with general dentist and appointment with preventive clinic to

complete prophy.

B. Want to see a halt in progression of recession and plaque build up through better home

care & over all oral hygiene, decrease bleeding and inflammation of the gums, and less

interproximal biofilm/debris.

C. No extensive further treatment necessary.

D. Preliminary phase: assessment (review pt. history, medical/ dental history, obtain vital

signs, & perform full extra-intra oral exam)

E. Phase 1 Therapy: Dental biofilm and plaque control, Biotene mouthwash, electric

toothbrush with thick handle, dental floss threader, FM plaque & calculus removal. Restore teeth

esthetically.

Implementation:

A. Comprehensive exam with general dentist to screen for possible caries and appointment

to complete prophy with preventive/ dental hygiene clinic. Updated periodontal exam, oral

hygiene instruction needed.

B. Universal Sickle Scaler (2O4S, for any tenacious anterior calculus), area specific

Curettes (Gracey 1/2, 11/12, 13/14), universal curette (Columbia 13/14), Periodontal Probe,

mouth mirror, Discoid-Cleoid (for heavy plaque removal and stain).

C. Hand scale full mouth and polish to complete prophy.

D. Discussed the use of an electric toothbrush or a foam grip auxiliary aid to make it easier

to hold the toothbrush since having a firm grip can come as a struggle due to the severe arthritis

on the hands. Recommend Biotene mouth rinse to use at home for dry mouth aid, demonstrate

BASS brushing technique with soft bristle toothbrush because of her recession and inflamed

tissues. Recommended using a floss threader because of the thicker/bigger handle to hold but

may need assistance threading the floss, super floss may be easier with the floss being thicker

and easier to get a hold on.

E. No anesthetic needed.

F. No prescriptions needed.

Evaluation:

A. Based off patients clinical findings (refer to: plaque score, calculus, radiographs &

probing depths) and over all presentation of her health and visually evaluating her body

language.

B. Disclose and develop new plaque score to look for improvement and calculus detection.

Full mouth periodontal probing at every appointment following to monitor any progress.

C. Take updated radiographs: CMS or 4 vertical bitewings to see if bone loss is stable or

regressed.

D. Ask pt to demonstrate their homecare habits to see if it is still correct technique and

discuss how brushing is going with arthritis, always follow up with how she is feeling overall and

if there are any concerns. Pt understands that good oral hygiene is critical for improvement.
References

Wilkins, E. M. (2017). Clinical practice of the dental hygienist (12th ed.). Philadelphia:

Wolters Kluwer.

Wynn, R. L., Meiller, T. F., & Crossley, H. L. (2016). Drug information handbook for

dentistry: Including oral medicine for medically-compromised patients & specific

oral conditions (22nd ed.). Hudson, OH: Lexicomp.

Hebl, L. (2017) Oral Pathology Powerpoint