PERIODONTAL CARE PLAN

Patient Name _____________ Age 25_____________

Date of initial exam_09/28/2017___________________ Date completed_11/30/2017_____

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.

This patient does not have any conditions that would alter treatment. She did have bronchitis and a fever
blister outbreak a few years ago but this is controlled. This patient does not require a pre-medication or a
medical clearance for treatment. This patient is not under the care of a physician and is not taking any
medications. She is allergic to Azithromycin, but it should have no effect. She has not been to a physician
in over 5 years which means it is a possibility that she could have any one of multiple systemic diseases
that could contribute to periodontitis. It is advisable to get a physical once a year. She does have an
alcoholic drink twice a week. Alcohol consumption can lead to a decrease in saliva flow which in turn
increases the risk of tooth decay and ultimately periodontitis. It is advised to drink in moderation to lower
this risk. Her vitals have been within normal limits

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)

Megan’s chief complaint and reason for visiting is to check for cavities and for a cleaning. Her last dental
visit was in 2014 for her wisdom teeth removal and a cleaning. She does not have a regular dentist and
has infrequent dental checkups which could contribute to her calculus build up and periodontitis. She
bleeds sometimes when she flosses, which could be because of her periodontitis or lack of regular
flossing. Her teeth are also always sensitive to cold food and drinks which could be from her receding
gums. Her dental I.Q. I feel is low, but she did seem receptive to what I was telling her. I’m hoping that
she takes the education to help her overall oral hygiene.

3. Oral Examination: (lesions noted, facial form, habits and awareness, consultation)

The patient had a palatal tori on her hard palate. She does clench her teeth when she is stressed or nervous
which could have contributed to her attrition. She has an overbite and overjet of 4 mm and also a mid-line
shift of 1 mm to the right. It is recommended that she gets a night guard to help protect from any further
attrition The excessive forces and pressure from clenching can cause some alveolar bone resorption which
could continuously get worse over time. Her molar and canine occlusion were all class I with no open or
cross bites. Her facial form is mesognathic.
4. Periodontal Examination: (color, contour, texture, consistency, etc.)

a. Case Classification V Periodontal Case Type 2

b. Gingival Description:

App't 1: 9/28/2017
Her architecture was scalloped. Although, her color was red on her maxillary posterior and
mandibular lingual. While her consistency was edematous, margins were rolled and papillae
was bulbous on her facial mandibular lingual. She had no suppuration. Her papillary and
marginal surface texture was smooth and her attached surface texture was stippled.
 App't 2: 10/29/2017
Her architecture was scalloped. Her maxillary posteriors and facial mandibular linguals were red
in color. The consistency was edematous, margins were rolled and papillae was bulbous on her
mandibular linguals. No suppuration was evident. Her papillary and marginal surface texture was
smooth and her attached surface texture was stippled.

App't 3: 11/2/2017
Her architecture was scalloped. Her maxillary posteriors were red in color and mandibular left
linguals were pinkish in color. The consistency was slightly edematous, margins were rolled and
papillae slightly bulbous on her mandibular linguals. No suppuration was evident. Her papillary
and marginal surface texture was smooth and her attached surface was stippled.

App't 4: 11/8/2017
Her architecture was scalloped. Her maxillary posteriors were red in color and mandibular
linguals were pinkish in color. The consistency was slightly edematous, margins were rolled and
papillar slightly bulbous on her mandibular linguals. No suppuration was evident. Her papillary
and marginal surface texture was smooth and her attached surface was stippled.

App't 5: 11/15/2017
Her architecture was scalloped. Her maxillary posteriors were reddish in color. The consistency
was slightly rolled on her mandibular linguals. No suppuration was evident. Her papillary and
marginal surface texture was smooth and her attached surface was stippled.

App't 6: 11/30/2017
After cleaning the entire mouth and waiting two weeks to allow the tissues to heal,
improvements were made from the first appointment. Her architecture was scalloped. Her
maxillary posteriors were pinkish in color and mandibular linguals were slightly red (calculus
was built up again). The consistency was slightly edematous and margins slightly rolled. Papillae
was normal. No suppuration was evident. Her papillary and marginal surface texture was smooth
and her attached surface was stippled.

c. Plaque Index: App’t 1 3.0 (fair) 2 1.6 (good) 3 1.6 (good) 4 1.5 (good) 5 1.8 (fair) 6 1 (good)

d. Gingival Index: Initial 1.4 (fair) Final 0.4 (good)

e. Bleeding Index: App’t 1 5.3% 2 0.1% 3 0.01% 4 0% 5 0.02% 6 0.05%

f. Evaluation of Indices:
1. Initial
Evaluating her indices shows proof that she does have periodontal disease. Generalized in each
quad is moderate inflammation with bleeding upon probing. This is a direct indication that
periodontitis could be involved. Her plaque score was a 3 which is fair. Most of her plaque
accumulation is interproximal, which can be prevented with flossing, and at the gum line which
could indicate she is not brushing well enough. Her bleeding score was 5.3% which could mean
she has calculus subgingival. Overall, her indices are fair which I’m hoping we can bring up to
good.
 2. Final
My patient’s indices all improved drastically, exceeding our long and short term goals. During
our first appointment, I did stress the importance of good oral home care and the difference it
can make in her mouth, it is evident she took this information and worked to improve her
numbers. Her average plaque score for the next 5 appointments was a 1.5 (good). Her last
appointment she ended up having a 1.0 (good) for her plaque score. Her average bleeding score
was 0.04 % with her last appointment she had a 0.05%. We wanted to halt the progression of her
periodontitis and we accomplished this. Each appointment I continued to praise her for lowering
her numbers, which I think had an effect on her home care as well. I was very proud of the
improvements she made!

Chart: (Record Baseline and First Re-evaluation data)

1.Baseline
The highest probing pockets the patient had was a few 6-7 mm pockets in the posteriors. She also has
quite a few 4-5 mm pockets generalized through her mouth. She has recession of 1 mm on teeth # 20-
21. It is important to remove the plaque and calculus build up to halt the progression of her
periodontitis.

2.First Re-revaluation
After completing the treatment of ultrasonic and fine scale of my patient’s whole mouth, we waited
two weeks to allow the tissues to heal so we could see the results. Her pocket depths had major
impovements. She had one 6 mm, two 5 mm and seven 4 mm pockets all localized to the posterior
teeth. She did have a few 1 mm of recession on teeth # 19-21, 25 and 28-30. My belief for the new
spots of recession is there was calculus there that we removed that was previously hiding the
recession. Even with the new recession spots, we were very happy with her new numbers. She is
close to having all healthy pocket depths with the continuation of what she has been doing.

5. Dental Examination: (caries, attrition, midline position, mal-relation of groups of teeth, occlusion,
abfractions) This patient has extracted teeth #1,16,17,32. She has hypoclassification on #2-5,11-
15,17-20,28-31 She has attrition on #7-10. The patient has torsoverion on #23-24,26 and lingoversion
on #25 which can and has caused a lot of build-up that can make it hard to clean and contribute to her
periodontitis. She has amalgam on teeth #4 DO, MO, #5 MO #6 MI #30 DO #31 MO The patient has
an overbite of 4 mm and overjet of 4 mm with a mid-line shift 1 mm to right.

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

App't 1:
At this appointment, we started gathering information. I took film vertical bitewings at this
appointment to accompany the FMX we took last year. I performed a head and neck/intra oral
examination, dental charting with x-rays, and a periodontal assessment and got it all checked.
We also filled out an informed consent and a risk assessment form. At this appointment, she
committed to being my periodontal patient this semester. I filled out the gingival index form and
got her probe depths. We talked about her periodontal pockets and how to halt them. Her
learning level was unaware but seems very concerned.

App't 2: At this appointment we will update her medical/dental history, pre rinse take some
intra oral photos of her teeth to show her “before and after” photos. We will also be doing
another plaque index, gingival description and bleeding score on this appointment and all the
following appointments. At this appointment we will be discussing her long and short term goals
and go into first patient education.
PE # 1 – Our goal is to reduce her plaque score to a 1.5. I will ask her if she can define plaque
and ask her to show me how she brushes her teeth. I will then correct or praise her on her
definition of plaque and demonstrate the “bass” brushing technique. I will tell her the importance
of brushing correctly and how it removes the plaque and bacteria that resides in her mouth. We
will discuss her plaque score and hopefully bring it down to a 1.5. I will then tell her briefly that
our next patient education topic will be about flossing and periodontitis and review what we
learned.

(Brushing and plaque)

LTG 1 – Patient will reduce plaque score from 3.0 to 1.5 by our last appointment
STG – define plaque
STG – correctly demonstrate proper “bass” brushing technique
STG – lower plaque score by 0.3 each appointment

(Flossing and periodontitis)

LTG 2 – Patient will reduce bleeding score from 5.3% to 1% by our last appointment
STG – define periodontits
STG – correctly demonstrate flossing
STG – reduce bleeding score by 1% each appointment

(Mouth guard and bruxism)

LTG 3 – Patient will buy a mouth guard for clenching/bruxism by our last appointment
STG – define bruxism
STG – wear the mouth guard

App't 3: We will update medical/dental history and prerinse. We will then take plaque index,
check gingival description and get a bleeding score. Next we will have her patient education over
flossing and periodontitis.
PE #2 - Our goal is to halt the progression of her periodontitis. I will ask her to define
periodontitis and to show me how to floss. I will then praise or correct her on her definition of
periodontitis and show her the correct flossing method which is wrapping the floss around the
fingers and making a C shape against the tooth and under the gingiva. We will discuss her pocket
depths and why it’s important to bring them down from a 7 and how flossing will aid in that.
Then we will briefly talk about her next patient education topic which is bruxism and a mouth
guard. We will last review what we learned in this appointment and the previous appointment.
We will then ultra sonic, fine scale and perio chart her mandibular left quadrant.

App't 4:
We will update medical/dental history and prerinse. We will then take plaque index, check
gingival description and get a bleeding score. Next we will have her last patient education over
mouth guards and bruxism.
PE #3 – Our goal for this appointment is to get the patient to buy a mouth guard. I will first ask
her to define bruxism. I will then praise or correct her on her definition of bruxism. We will talk
about the importance of a mouth guard and what it can prevent. We want to stop anymore
attrition from happening from her stress clenching which I think happens at night and she doesn’t
realize it. We will then review what we learned about bruxism and also what we learned in the
last two appointments.
We will then ultra sonic, fine scale and perio chart her maxillary left quadrant.

App't 5:
We will update medical/dental history and prerinse. We will then take plaque index, check
gingival description and get a bleeding score. We will have chair side patient education and
make sure she remembers and understands the importance of correct brushing. Then we will
ultra sonic, fine scale and perio chart her mandibular right quadrant.

App't 6:
We will update medical/dental history and prerinse. We will then take plaque index, check
gingival description and get a bleeding score. We will have chair side patient education and
make sure she remembers and understands the importance of correct flossing. Then we will ultra
sonic, fine scale and perio chart her maxillary right quadrant.

App't 7:
At her final appointment we will update medical/dental history, prerinse and do final plaque
index and bleeding score. We will then assess her gingiva, periodontal pockets and gingival
index. I will acquire final periodontal charting, post calculus and Arestin. We will compare her
periodontal pockets and plaque score and explain what we found out. We will then do plaque
free and apply fluoride. She will be on a 3 month recall to assess her periodontitis. Then give
final gingival statement.

7. Radiographic Findings: (crown root ratio, root form, condition of interproximal bony
crests, thickened lamina dura, calculus, and root resorption)
The patient has mild horizontal bone loss on her lower anteriors from teeth #23-26. This is most
likely from her periodontal disease. She also has dilaceration on teeth # 4 and 13. The x-rays also
show calculus on teeth #23-26.

8. Journal Notes: (Record in detail the treatment provided, oral hygiene education, patient response,
complications, improvements, diet recommendations, learning level, progress towards short and long
term goals, expectations, etc.) The progress notes should be written by appointment date.
Appt. 1 (9/28/2017)
At our first appointment, we updated her medical and dental history, signed the statement of release,
took vitals (normal) and pre-rinsed. We took film vertical bitewings to check for bone loss to refer to
for all appointments. Then we did her extra/intraoral exam. She had development palatal tori. She
said she doesn’t grind her teeth, but after looking at her dental charting we decided she did. She did
say that she clenches when she is stressed or nervous. Then we did her periodontal assessment where
we noted that she had red maxillary posterior facials and mandibular linguals. She also had
edematous/spongy consistency, rolled margins and bulbous papillae on her mandibular lingual
anteriors. Her surface texture (papillary & marginal) was smooth and her surface texture (attached)
was stippled. We checked her radiographic findings where we found root dilaceration on tooth #3 and
calculus on #14. We then did her dental charting with her x-rays (findings stated above). We took her
initial gingival index which was a 1.4 (fair). This showed she had generalized moderated
inflammation with bleeding upon probing. Then we took her plaque and bleeding score (stated
above). She used a medium toothbrush and horizontal brushing method. She brushes twice a day and
doesn’t floss or rinse. She uses crest toothpaste with no known fluoride. We then did her risk
assessment which showed she was low risk for oral pathology, but high risk for periodontal disease
and caries. Then we did her informed consent. We had chair side patient education where we talked
about halting her perio. To do this she needs to start flossing at least once a week. Her learning level
was action. She does drink at least two cups of coffee with cream and sugar everyday, if not more and
I told her we need to try to lessen that, not only for the health of her teeth but for her nutritional health
too. There were no complications during this appointment.

Appt. 2 (10/19/2017)
At her second appointment we updated her medical and dental history, took her vitals (normal) and
pre-rinsed. We then got the intraoral camera to take photos of her mandibular anterior linguals to
show her built up calculus and recession. We took her plaque and bleeding score (stated above). We
had our first patient education session where we talked all her long and short term goals, defined
plaque and then demonstrated brushing correctly using the “bass” method to bring down her plaque
score from a 5.3 to a 1.5. We demonstrated on the typodont and then she showed me on her own
mouth. I made sure to show her to angle the toothbrush at 45 degree angle towards the sulcus and not
to brush too aggressively to avoid damaging the tissues and removing the enamel. Her learning level
was involvement. We then ultra-sonic scaled her mandibular left and perio charted that quad. There
were no complications during this appointment.

Appt. 3 (11/2/2017)
At her third appointment, we updated her medical and dental history, took her vitals (normal) and pre-
rinsed. We took her plaque and bleeding score (stated above). We then did calculus detection. Then
we ultra-sonic and fine scaled her mandibular right quad. Then we perio charted. We did chair side
patient education where we explained what the ultra-sonic is and why we used it on patients. Her
learning level was aware. There were no complications during this appointment.

Appt. 4 (11/8/2017)
At her fourth appointment, we updated her medical and dental history, took her vitals (normal) and
pre-rinsed. We took her plaque and bleeding score (stated above). We anesthetized her using 2 carpels
of lidocaine Hcl 2% with epinephrine 1:100,000. We then ultra sonic and fine scaled her maxillary
right. Then we perio charted that quad. We had chair side patient education about flossing again, to
stress the importance of cleaning interproximally and under the gums. Learning level was aware.
There were no complications during this appointment.

Appt. 5 (11/15/2017)
At her fifth appointment, we updated her medical and dental history, took her vitals (normal) and pre-
rinsed. We took her plaque and bleeding score (stated above). We anesthetized her using 1 carpel of
lidocaine Hcl 2% with epinephrine 1:100,000. Then we ultra-sonic scaled maxillary left and went
back over mandibular right. Then we fine scaled maxillary left, mandibular left and right. Then I
perio charted maxillary left quad. We then had our second patient education session where we
reviewed long and short term goals. We then defined periodontitis and went over flossing on the
typodont using a C-shape motion to go subgingivally which can help with her bleeding score. She
then she me on herself that she can floss correctly. We talked about how perio is irreversible, but it
can be halted. I reminded her about the amount of sugar intake from her coffee and suggested trying
half the amount of sugar and creamer and this didn’t seem attainable, to make sure to brush after
having her coffee. There were no complications during this appointment.

Appt. 6 (11/30/2017)
On her last appointment, we updated her medical and dental history, took her vitals (normal) and pre-
rinsed. We took her plaque and bleeding score (stated above). We got her last gingival index score 1.0
 (good). We did post cal to make sure there was no residual calculus that could cause an abscess. Then
we did full perio charting, showing all the improvement she made in her pocket depths. We did
plaque free to make sure we removed all calculus, stain and plaque. We then placed a sealant on tooth
#18 to help prevent decay in her deep grooves. Then we placed Arestin on teeth #14,15 and 31
because they had a 6 mm, 5mm and 5mm pocket on the distals. This is help close up pocket depths
5+. Then we put fluoride varnish on her teeth (5% NaFl). We retook her vertical bitewings because I
had missed the distals of the molar and canines. We had our last patient education session where we
reviewed the long and short term goals and she showed me she could still brush and floss correctly to
be the most effective. We then defined bruxism and what effect this has on her teeth like tooth
sensitivity. We reached our long term goals of bringing the plaque score to 1.5 and bleeding score to
1%, unfortunately she has no bought a mouth guard yet but said she went last night to Target to get
one but forgot. She does still plan on getting one. Her learning level was action. There were no
complications during this appointment.

9. Prognosis: (Based on attitude, age, number of teeth, systemic background, malocclusion, tooth
morphology, periodontal examination, recare availability)
Based on all the appointments that we had and information that I gathered, I believe the
prognosis of my patient is good. She seems genuinely interested in learning and even told me she
noticed calculus on other people that she had previously not noticed. This says to me that she is
taking information I have given her and using it in real world situations and educating others.
She is only 25 which means she is still young enough to not be set in her ways, she has expressed
changes in flossing which she hadn’t before. I did recommend starting with flossing once a
week, but at this time she is doing sporadically which I hope will change. She has all of her
dentition except for her third molars that was surgically removed. She does not have anything
going on systemically that could affect her halting the perio and keeping it halted. She is also not
taking medications. Unfortunately she does have malaligned mandibular anteriors that plays a
big role in her perio. Her mandibular left quad is the first one I cleaned and when she came back
for her re-evaluation she had already accumulated calculus in that area. I stressed the importance
of flossing, especially in this area to reduce the calculus build up. Other than that, her results
from the re-eval appointment were highly improved. She said she take off from work if she gives
a 2 week notice so she can come back in the Spring for her recall appointment which means she
is dedicated to making a change because previously she had not been going to the dentist.

10. Supportive Therapy: Suggestions to patient regarding re-evaluation, referral, and recall schedule.
(Note: Include date of recall appointment below.)
During my patient’s re-evaluation, I reminded her about how important flossing is for everyone,
but especially for her since she has malaligned teeth. I told her about floss picks because they are
a good start for someone who doesn’t floss regularly. I told her to start with once a week because
that seems like the most likely she would do it, although she hasn’t started that yet. I told her it is
also important to keep going to the dentist. She hadn’t been in a few years and before that it had
also been a few years. I told her because she has perio she needs to be on a 3 month recall until
we get in under control and it is no longer active and she can then be on a 6 month recall. Her
recall appointment is for the end of February of 2018.

11. Assessment of Changes: (including plaque control, bleeding tendency, gingival health, probing
depths)
During the re-evaluation, we did all of the assessments again to see what improvements had been made
from her first to last appointment. Her plaque score went from a 3.0 (fair) to a 1.0 (good). This
 shows she is implementing correct brushing methods and brushing two times a day. Because of her
malaligned anteriors, they accumulated plaque and she has made a major improvement in that area.
Her bleeding score also went from a 5.3% to a 0.05%. Her probing depths improved from multiple 6
and 7 mm pockets to just one 6 mm and two 5 mm and seven 4 mm pockets which is a big difference
and shows her attachment levels are improving too. Her gingival index also improved by decreasing
from a 1.4 (fair) to a 0.4 (good) which meant she went from generalized moderate inflammation with
bleeding upon probing to generalized healthy, normal tissues.

12. Patient Attitudes and Cooperation:

My patient had an overall positive attitude towards her treatment. She didn’t complain about
having to come in so much and for multiple hours at a time even though she works a full time
job. She asked a lot of questions and paid attention to what I had to say. She picked up on a lot of
the terms I would say to the instructors and would ask what they meant and remembered them.
She told me she was able to now see calculus on people and was so happy to have hers removed
since before coming to see me, she hadn’t noticed it or known what it was. She came into her
patient education sessions eager to learn and remembered the definitions she learned from the
previous sessions. After learning about her irreversible disease, she willing to make a change to
improve her oral health. It’s a good feeling to have a patient change how the feel about going to
the dentist so they can have a healthier mouth.

13. Personal Evaluation/Reaction to Experience:

This project was a real eye-opener for me. Most of the patients I have seen had minimal tissue
problems other than a little inflammation and bleeding. To see the transition from unhealthy to
mostly healthy tissue was such a great feeling. I also feel that it educated me more in the
periodontal assessment area which is very important because this is where the hygienist see the
first signs of periodontal disease.