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Tx Plan #2

Kendre Kamm

April 28, 2018

Assessment:

A. Minor sensitivity to cold, areas of food impaction on the lower mandibular teeth

#19-20, sore jaw sometimes when chewing hard foods.

B. Patient has had previous orthodontic tx (braces), extraction of 3rd molars and

#15 due to apical abscess.

a. Medications:

i. Zoloft (50 mg) for tx of depression/social anxiety, OCD, panic

disorder, PTSD; can cause xerostomia & may impair platelet

aggregation resulting in increased risk of bleeding.

ii. Alprazolam (0.25 mg) when needed for tx of anxiety/panic attacks;

can cause xerostomia.

iii. Aspirin (81 mg) to control high blood pressure; can cause

prolonged bleeding.

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

when changing positions during or after dental tx.

C. Patient does not smoke or drink.

D. BP: 112/78
E. Extra Oral:​ Hearing aid on right ear, TMD slightly more pressure on left side, pt

mentioned slight pain in neck on left side, small palpable lesion on outer border

of lower lip. ​Intra oral: l​ ower lip lesion (pt says it has been present for about a

week & is from biting his lip), tonsils are absent, minor chapped lips. ​Plaque

score:​ 21%. ​Perio case type:​ GEN Healthy. ​Calc Class:​ A

F. No periodontal probing measurements on file. (Need FM periodic exam) Visible

gingival recession on #19, 30, 31, 13, 6, 11,3.

G. No radiographs on file.

DH Diagnosis (Problem Identification)

A. Oral health:​ Good. ​Physical health:​ Fair

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

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 through better home care & over

all oral hygiene, decrease sensitivity.

C. No extensive further treatment necessary.

​ ssessment (review pt. history, medical/ dental history, obtain


D. Preliminary phase: a

vital signs, & perform full extra-intra oral exam)


E. Phase 1 Therapy:​ Dental biofilm control, mouthwash, toothbrush, dental floss,

FM plaque & calculus removal, and topical fluoride varnish.

Implementation:

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

appointment to complete prophy with preventive clinic.

B. Universal sickle scaler (for any tenacious anterior calculus), area specific curette

(gracey 1/2, 11/12, 13/14), periodontal probe, mouth mirror.

C. Recommend fluoridated mouth rinse to use at home, demonstrate BASS

brushing technique with soft or extra soft bristle toothbrush because of his

recession, have dentist prescribe Prevident 5000+ Booster Plus Sensitivity

toothpaste to help reduce sensitivity.

Evaluation:

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

& probing depths when taken)

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

detection.

C. Take updated radiographs: CMS.

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

record new plaque score and every appointment following.


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.