Sonya Bautista
PERIODONTAL CARE PLAN
Patient Name: _Olvin Noe Avila Age: _30_
Date of initial exam: _September 4, 2015 Date completed: __November 6, 2015__
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.
Patient does not have a specific physician that he goes to and does not go regularly. He only goes to the emergency room. Patient claims to have had his last physical in July of 2015. Although, by this he meant he went to the emergency room because of painful rash on his body. Doctor told him he had shingles and patient was given medication for it. Patient finds his general health to be in good condition but having no physician can mean he could have health problems and not be aware of them. Patient claims to have no health conditions and was found to have prehypertension on his first visit.
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)
Patient’s chief reason for his visit is to get a dental cleaning. Patient has never received a dental cleaning before. He’s never actually had a dentist either. Patient has only been to the dentist to get #3 and #30 extracted and had radiographs done on him while he was there in August 2015 before coming to LIT. He has not had any problems with dental treatments. Patient brushes teeth at home with a hard toothbrush twice a day using the charter’s method. He also flosses three times a week. Patient sometimes bleeds when brushing and flossing. His bleeding gums affects the diagnosis in which bleeding is a sign of unhealthy tissues. Patient feels tooth sensitivity with cold drinks and food and this could be from exposed root exposure that the patient is not aware of which could have come from using a hard toothbrush. During the patient’s first appointment, he had moderate bleeding throughout his whole mouth. Patientalso mouth breathes while wearing a mask at work. Xerostomia has not been a problem for patient but mouth breathing does cause less saliva to flow through the mouth which allows more bacteria to be present and more demineralization to occur. Patient has 3 sugary drinks daily. This also contributes to demineralization within the mouth putting the patient at a higher risk for caries. Since patient does not go to the dentist on a regular basis and has never had a cleaning, he is completely unaware of the condition of his oral health. His lack of dental visits has led his oral hygiene and oral education to suffer greatly for the past 29 years. Over time the patient developed periodontal disease and due to his lack of education, it has progressed and the patient has not known how to put a stop to it. He does not fully comprehend he has a disease. Patient is not happy with the appearance of his teeth and says they do not look very good. This feeling towards his teeth can serve as a motive to change his oral habits. Patient is happy he can finally get a cleaning and is eager to start building up his oral hygiene and education.
3. Oral Examination: (lesions noted, facial form, habits and awareness, consultation)
During the extra oral exam, patient was found to have bilateral submandibular lymphadenopathy from a previous infection in the past. Lymph nodes were not causing any pain to the patient and are not tender. Patient experiences popping in his TMJ when opening his mouth. He is aware of the popping but TMJ does not hurt him or bother him. His TMJ also deviates to the left when opening his mouth and then deviates to the right when closing his mouth. He suspects this is from playing soccer where he’s gotten hit various times. Patient should use a mouth guard when playing soccer to avoid further injury. Intraorally, the patient has a palatal torus and also has bilateral mandibular tori. Patient has very slight linea alba on his buccal mucosa where it looks like it is from his occlusion. He has an unclassifiable right molar occlusion because he is missing teeth #3 and #30. His right canine relation is a class I with a tendency to class II. Patient’s left molar occlusion is a class I while his left canine is a class II. Patient has a 3 mm overbite, 3 mm overjet, 1 mm mid-line shift to the right, no open bites, and no cross bites. Patient clenches and grinds his teeth when sleeping. He realizes his mouth is a little sore sometimes when he wakes up in the mornings so he is aware of this habit. Patient should be using a night guard to prevent further damage. Clenching and grinding has caused attrition in the patient’s mouth, TMJ issues, and has contributed to his bone loss, loss of periodontal ligament attachment allowing his periodontal disease to progress further.
4. Periodontal Examination: (color, contour, texture, consistency, etc.)
a. Case Classification ___8___ Periodontal Case Type___III___
b. Gingival Description:
App’t 1:9/4/15
During the first appointment, the patient had generalized scalloped gingiva on the lingual and facial side with the exception of tooth #10 facial which was flat. Generalized redness was found all along the margins and papillae of the teeth both facially and lingually. Patient’s gingiva had a spongy/edematous consistency throughout the entire mouth. The gingival margins were rolled, especially on the facials of the mandibular premolars. The papillae were bulbous throughout the whole mouth but mostly on the linguals of the mandibular anterior. No suppuration was found in the mouth when probed nor when palpated. Gingiva was found to be smooth and shiny throughout the entire mouth and the attached gingiva is still stippled.
App’t 2:9/18/15
For the second appointment, the gingiva remained the same. The patient had generalized scalloped gingiva on the lingual and facial sides with the exception of tooth #10 which was flat on the facial side. Generalized redness was found all along the margins and papillae of the teeth on the facial and lingual. Patient’s gingiva had a spongy/edematous consistency throughout the whole mouth. Gingival margins were rolled generalized but more emphasized on the facials of the mandibular premolars. Papillae were bulbous, mostly on the mandibular anterior linguals. The gingiva was smooth and shiny throughout the whole mouth with a stippled attached gingiva. No suppuration was found in the mouth when probed/palpated.
App’t 3:9/25/15
For the third appointment, I noticed a change in the patient’s maxillary right quadrant. The patient’s maxillary right quadrant improved in color. It did not appear as red as it did on his last visit and both the marginal and papillary swelling had gone down. The patient continued to have generalized scalloped gingiva on both the lingual and facial aspects of his teeth with the exception of tooth #10 which was flat along the facial side. Generalized redness was still found along the margins and papillae of the remaining three quadrants, facially and lingually. The patient still experienced a generalized spongy/edematous gingival consistency throughout the whole mouth. The gingival margins were generalized rolled with still an emphasis on the facials of the mandibular premolars. The mandibular anterior linguals were also more bulbous compared to the rest of the mouth. The gingiva had a smooth and shiny appearance with stippled attached gingiva. Upon probing and palpating, no suppuration was found.
App’t 4:10/9/15
During this visit, I noticed just how much his maxillary was improving, now that his whole maxillary arch was cleaned. The whole maxillary had reduced swelling and redness. Inflammation is not completely gone, but it’s getting there. The patient has generalized scalloped gingiva throughout the whole mouth both on the facial and lingual sides. He continues to have generalized spongy/edematous gingiva for the entire mouth with generalized rolled margins. The rolled margins are more prominent in the mandibular facial premolars and the bulbous papillae are more prominent in the anterior linguals of the patient’s mouth. The gingiva has a smooth, shiny appearance along the margins and papillae and a stippled appearance on the attached gingiva. There was no suppuration found when probing and palpating the patient’s gingiva.
App’t 5:10/16/15
There is a significant amount of reduced redness, swelling, and bleeding as well in both the maxillary and mandibular. The patient has generalized scalloped gingiva with the exception of tooth #10 on the facial aspect. The patient has slightly spongy gingiva on his maxillary arch and reduced spongy gingival tissue on the mandibular right quadrant. Patient has reduced bulbous papilla on the mandibular right quadrant, but the left mandibular quadrant still has prominent bulbous papillae on the anterior linguals. Patient has generalized rolled margins, especially on his mandibular premolars. Gingival margins and papillae have smooth, shiny appearance and the attached gingiva has a stippled appearance. No suppuration was found when probing or palpating the gingiva during the appointment.
App’t 6:11/6/15
Patient showed up for post periodontal and post calculus appointment three weeks after last appointment. Redness was no longer seen along the maxillary margins and interdental papillae. A firmer tissue is now seen. Gingival tissue still has scalloped gingiva with the exception of tooth #10 which continues to be flat. Redness overall was reduced throughout the whole mouth. The whole maxillary arch presented itself with a pink gingival appearance. The mandibular arch however, still showed slight redness along the linguals of the mandibular molars. Redness was observed all around the mandibular anteriors with bulbous papillae also present on the mandibular anteriors. Pockets depths, swelling, and bleeding have reduced significantly due to patient’s improved oral care and determination of halting his periodontal disease.
c.Plaque Index: App’t 1__Fair – 2.0 _ 2__Fair – 1.8__ 3__Fair – 2.3 _ 4__Good – 1.0__ 5__Good – 1.5 _ 6__Good – 1.3__
d. Gingival Index: Initial __Poor – 2.1__ Final __Fair – 1.3__
e.Bleeding Index: App’t 1__54.4%__ 2__41.7%__ 3__33.3%__ 4__33.3%__ 5__37.5%__ 6__29.2%__
f.Evaluation of Indices:
1. Initial
Patient has moderate periodontitis. On his first visit, patient had a plaque score of 2.0 being fair. I find this score to be a bit misleading, because I had already probed his mouth before taking the plaque score so there was less plaque present along the margins of the teeth when I took his plaque score. His bleeding was 54.4%. When probed, he had generalized moderate bleeding pretty much everywhere with severe bleeding on the lingual of his mandibular anterior teeth and buccal and lingual of his maxillary molars. The gingival index lets us know first off that the patient had inflammation everywhere. There was no sign of healthy tissue in his mouth. He had more inflammation on his mandibular teeth than on his maxillary. Patient had more inflammation toward his mandibular anterior sextant. Plaque or better yet, the bacteria within his mouth has led him to this chronic periodontitis and the calculus that has been sitting on his teeth has caused his gingiva to be moderately inflamed. The bleeding comes from his inflammation and lets us know how his inflammation is doing.
2. Final
During patient’s final appointment, a significant amount of gingival inflammation had gone down. Patient is demonstrating improved oral hygiene and his scores along with his gingiva are clinically showing it. Patient’s plaque score was reduced to a good level of 1.3 compared to his fair level of 2.0 when he first came into the clinic. Bleeding score was also reduced to a 29.2% compared to his 54.4% bleeding. Gingival index improved because of plaque and bleeding improvement. Gingival index is now at a fair state of 1.3 compared to his initial poor state of 2.1.Gingival inflammation was mainly found on the mandibular anterior teeth. Now that all calculus has been removed, patient’s gingival index has been improving because the bacteria that was continuously irritating the gingiva is now gone and the gingiva can now begin to heal. However, complete healing will depend entirely on patient’s daily oral hygiene.
g.Periodontal Chart: (Record Baseline and First Re-evaluation data)
1.Baseline
Patient’s periodontal charting will be completed by quadrants due to the supra and subgingival calculus build up that the patient has. 52 pocket depths were found to be 4mm, 45 pocket depths were 5mm, 14 pocket depths were 6mm, and 4 pocket depthswere 7mm deep.Patient’s deeper pockets are found in the interproximals. Patient does not have any furcation involvements, frenal problems, inadequate zone of attached gingiva, nor did he have sensitivity to percussion, or suppuration and mobility. With all the pocket depths that the patient has, plaque can easily hide in his deep pockets and make it more difficult for the patient to remove plaque thus allowing his periodontal disease to progress to a more advanced level causing more destruction of the periodontium.
2.Firstevaluation
Patient’s pocket depths have improved significantly throughout the treatment. The deepest pocket found during the patient’s final visit was a 5. He had 52 pocket depths of 4 mm and 8 pocket depths of 5 mm. The patient no longer had existing pockets deeper than 5 mm. These deeper pocket depths were found on interproximally, mainly just on the posteriors but a few 4 mm pocket depths were found on the maxillary anteriorsinterproximally as well. It can be determined that pocket depths have been healing with each appointment every time calculus was removed and with patient’s self-care at home. Now that the patient flosses daily and brushes subgingivally, patient is halting the progression of periodontal disease through the daily removal of bacterial plaque.
5.Dental Examination: (caries, attrition, midline position, mal-relation of groups of teeth, occlusion, abfractions)
Patient has caries on the occlusals of #2, and 18 that were referred at our clinic for caries, as well as #8M, #32B. The patient has attrition on all anterior teeth, both maxillary and mandibular plus patient’s maxillary premolars. He has a 1mm mid-line shift to the right with an overbite and overjet of 3 mm. Patient does not have an open bite or cross bite. His right molars were unclassifiable because both #3 and #30 are missing. Patient’s left molar is a class I, while his right canine is a class I with a tendency towards class II. His left canine is a class II. Patient also has a diastema on both sides of #11. Patient’s bruxism habit contributes to his periodontal disease in which bruxism applies pressure and creates tension within the patient’s periodontal ligaments and the alveolar bone. These unnecessary forces have served as an aid in his progression of periodontal disease.
6.Treatment Plan: (Include assessment of patient needs and education plan)
App’t 1: 9/4/15
Patient’s first appointment was to take radiographs and do paperwork. Patient filled out medical/dental history and signed State of Release, HIPPA, and Patient Practice. Patient pre-rinsed and had a panorex done. Extra and intraoral exam along with periodontal assessment dental charting, risk assessment, and plaque score along with bleeding score were completed. Informed consent was signed. Patient was at appointment for 4 hours.
App’t 2:9/18/15
This was a four hour appointment. An update of the medical/dental historywas taken and the patient pre-rinsed. Intraoral pictures were taken to show “before treatment” pictures to patient. Gingival index, plaque score, and bleeding scorewere also taken during appointment. I used the ultrasonic on patient’s maxillary right quadrant and completed full periodontal charting on maxillary right quadrant. Anesthesiawas used on the patient (4% Septocaine w/ epi – 1:100,000 – 3.4 mL). I provided patient education on plaqueand demonstrated proper brushing to patient and started fine scaling his maxillary right quadrant.I did not finish fine scaling this maxillary right quadrant.
App’t 3:9/25/15
This will be a four hour appointment. An update of the medical/dental history will be done as well as pre-rinse. Plaque score and bleeding score will be taken during appointment. I will finish fine scaling patient’s maxillary right. I will ultrasonic patient’s maxillary leftquadrant and get full periodontal charting on maxillary left quadrant. Patient will need anesthesia (4% Septocaine with epi – 1:100,000 – 6.8 mL was used). I will provide patient education on periodontitis to patient and demonstrate proper flossing. Then I started fine scaling his maxillary left quadrant.
App’t 4:10/9/15
This will be a four hour appointment. An update of the medical/dental history will be done as well as pre-rinse. Plaque score and bleeding score will also be taken during appointment. I finished fine scaling patient’s maxillary left quadrant. I will ultrasonic patient’smandibular right quadrant and get full periodontal charting on mandibularright quadrant. Patient will need anesthesia (4% Septocaine with Epi 1:100,000 x 1.7mL was used in this quadrant). I will provide patient education on caries to patient and start fine scaling his mandibularright quadrant.