Jessica Fox

DH3 Treatment Plan

1. Assessment – Preliminary Phase

a. Patient Interview

i. Patient recently in for an extraction, #10. Was told she needed a cleaning.

Patient does not remember the last time she had a cleaning.

b. Medical/Dental History

i. Medication

1. Fluoxetine – Oral Effects; Xerostomia, Taste Perversion, SSRI-

induced bruxism

ii. Patient does not receive annual cleanings and does not remember when

her last cleaning was. Patient uses floss picks intermittently and makes

her own toothpaste which does not contain fluoride. Patient is only

receiving fluoride in water. Brushes with electric brush, but it does not

have batteries.

iii. Patient is hard of hearing and wears a hearing aid. Patient can read lips

and prefers to have the staff remove their masks when speaking so she

can understand the conversation. Patient also has neropathy.

c. Social History

i. Daily snacker – Snacks on chips, soda, chocolate, and fruit

d. Vital Signs
 i. BP 122/76

e. Intra/Extra Oral Exam

i. Maxillary frena tag

ii. Mandibular tori - Bilateral

iii. Maxillary tori – small almond shaped

iv. Tonsils - abscent

v. Uvula and Pharynx red – Pt asymptomatic

vi. Tongue – Tan coating present

vii. Attrition – Localized to mandibular anteriors

viii. Extrinsic staining – Very light

ix. Interdental Papilla – Generalized pointed and normal. Localized

flat/normal from 9-11. Localized bulbous to maxillary right posterior

quadrant.

x. Gingival Margin – Generalized knife-edge. Localized rolled in maxillary

right posterior quadrant.

f. Periodontal Exam

i. Generalized probing depths 2-3 mm.

ii. Localized 4 mm distal buccal of #3.

iii. Oral status has not improved since previous visit. Unsure how much OHI

was communicated/able to be communicated with patient at previous

visits.

g. Radiographs
 i. Localized horizontal bone loss at tooth #10 – which has been extracted

2. DH Diagnosis – phase 1

a. Level of Health

i. Patient is in fair health. Patient is physically capable of proper oral home

care, but lacking the motivation to implement a daily routine.

ii. Orally – Generalized healthy. Localized gingivitis in maxillary right

quadrant. Class B calculus

b. Diagnosis

i. Generalized healthy. Localized gingivitis (Maxillary right quad)

ii. Will be spending extra time on OHI with patient using tell-show-do to

ensure patient has a good understanding of adequate oral home care and

is able to perform the tasks.

3. Plan

a. Consultation – No need for consult at this time. – No need for phase 2 at this

time.

b. Treatment goals

i. Improved gingival health. Less plaque and calculus. Better OHI – Educate

patient about fluoride, current level of oral health and how to improve it.

Get batteries for electric brush Develop a routine of using the electric

brush and flossing. Discuss how to improve and reduce snacking choices.

Maintain perio case type.

c. Address phases of treatment

 i. Listed throughout plan

4. Implementation – At the time patient was seen 2 DHYG appointments were needed. If

seen today only 1 DHYG appointment would be necessary.

5. Consultations, instruments used, homecare aids, anesthetic, prescriptions

a. No consultation needed at this time

b. Probed FM with UNC 12 probe. Hand scaled FM with gracey curettes (1/2, 11/12,

13/14), sickle (H5/33), 11/12 explorer. Followed hand scaling with slow speed

prophy angle and medium paste. Patient declined fluoride varnish.

c. Advised patient to obtain batteries for electric brush. Dispensed floss picks and

floss reacher to encourage patient to develop a flossing habit. Sent home

fluoride toothpaste and encouraged use. Discussed brushing techniques. Asked

patient questions about what OHI was just explained to her and to perform

tasks. Patient understood and was able to perform proper angled, small circled

brushing and use of floss aids.

6. Evaluation – Phase 4

a. How will you evaluate care?

i. Improved plaque score, improve gingival tissue and interdental papilla,

particularly in the maxillary right quadrant.

b. Follow up charting

i. Perio chart – Probing depths maintained

c. Radiographs

i. Bitewing radiographs
 1. Bone loss maintained

2. Patient only has BW and Peris on file, no CMS. Would like to

discuss CMS at future visits to evaluate FM.

d. Pt. OHI behavior changes

i. Improved plaque score

ii. Patient utilizes recommended aids

iii. Patient develops an oral home care routine and DHYG recall routine

e. References

i. Wynn, R. (2017). Drug information handbook for dentistry. Wolters

Kluwer.

ii. Wilkins, E. (2017). Clinical practice of the dental hygienist. Philadelphia,

PA. Wolters Kluwer.