Student: Aimee Martin Patient: GINGIVAL INDEX PERIODONTAL CARE PLAN Patient

Initial date __10/11/2013_______________ Gingival Area M 3 (2) 9 12 19 25 28 1 1 1 0 0 1 F 0 0 1 0 0 1 D 1 0 1 1 1 1 L 1 1 1 1 1 0

TOTAL ___16/24 = .8%__________

Final date 11/22/2013 Gingival Area M 3 (2) 9 12 19 25 28 0 0 0 0 0 1 F 0 0 0 0 1 0 D 0 0 0 0 0 1 L 0 0 0 0 0 0

TOTAL

3/24 = .13%
PERIODONTAL CARE PLAN

Patient Name Patient Age 69 Date of initial exam 08/30/2013 Date completed 11/22/2013 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. Ms. Patient is a 69 year old black female. She is currently under the care of a physician and being treated for Type 2 diabetes and hypertension. Dental considerations for many of these drugs include monitoring vital signs and because she is diabetic, blood sugar levels must be monitored. These systemic diseases are being treated with a number of medications, taken daily, which are known to cause xerostomia, which allows bacteria to manifest and eventually lead to periodontal disease, and aid in plaque accumulation and retention. Notably, some of these medications she is currently taking are Lexapro, Carvedilol, Benazepril HCl, etc. During her initial oral exams, I noticed she had problems with dry mouth and mentioned this to her; recommending she try Biotene products. Although her diabetic condition is currently contolled, it seems to have played a role in her periodontal condition. Diabetes lowers a patients immune response and, in turn, when bacteria begin to attack periodontal tissues, the body is less able to fight off the infection. This leads to more severe bone loss in a shorter time frame than most other individuals. In the past, her oral self care might not have been enough to kill the bacteria causing plaque buildup that eventually led to her bodys immune response breaking down her periodontal tissues in an effort t o rid her oral cavity of the disease-causing anaerobic bacteria. Her dental care and treatments are infrequent and can attribute to the inability to halt progression of her periodontal disease prior to its inactive state. I will educate her as much as possible on medication effects and the importance of frequent dental exams. 2. Dental History: (past dental disease, response to treatment, dental I.Q., attitudes, chief complaint, present oral hygiene habits, effect on dental hygiene diagnosis and/or care) Ms. Patient does have a dentist and a periodontist she has seen prior but does not visit them on a regular basis. Her chief complaint in receiving treatment at our clinic this semester is a cleaning. She is a very cooperative patient and willing to come multiple times to receive the best oral care possible that we are able to provide. She does have somewhat of a problem getting sleepy in the chair. She seems to be aware of what can be done to aid in her oral care but it does not appear she performs all recommended hygiene steps to achieve optimal health. During her first two visits, I noticed she had either eaten after she brushed her teeth that morning or had not brushed well due to the large amounts of materia alba present on certain

teeth. On her third visit, when paperwork and data collection were complete, I noticed the amount of plaque accumulation was much lower. Overall, her plaque score has been low according to the teeth scored. She also have only very mild, generalized gingival inflammation and bleeding was only noticed on the first appointment. She does not, however, brush and floss as often as she should. She brushes at least once per day and sometimes twice but she only flosses up to twice per week at this point. She has several open contact areas where plaque can accumulate. She does also use a mouth rinse daily. She has a few pockets deeper than 4mm scattered throughout her periodontium. Ms. Patient has a lot of recession on her mandibular arch with nearly every tooth presenting a mm or more and on her maxillary arch, almost half her teeth present with recession. This loss of attachment is evidence of moderate periodontal disease. Ms. Patient has a positive attitude about improving her oral health and I look forward to working with her and teaching her methods of improvement.

3. Oral Examination: (lesions noted, facial form, habits and awareness, consultation) During her initial exam, she was found to have enlarged, bilateral submandibular lymph nodes. Patient did not recall being ill recently so it could be attributed to a latent infection or she could just have prominent glands. Ms. Patient stated she grinds her teeth at night and she does have attrition on all her maxillary and mandibular teeth. This causes trauma to her PDL and it begins to separate from the tooth structure. This can increase the likelihood of bone resportion. She also admits to breathing through her mouth when she is short-winded. She showed signs of very mild, generalized gingival irritation but otherwise, healthy gingival tissues were recorded as her periodontitis seems to be inactive at this point. After being examined by the dentist, nothing unusual was noted that would be of concern for further referral at this time.

4. Periodontal Examination: (color, contour, texture, consistency, etc.) a. Case Classification 4 Periodontal Case Type 3 b. Gingival Description: Scalloped architecture, generalized rolled margins (most notably in the mandibular anterior arch), normal consistency, smooth and shiny appearance, normal papilla, very slight generalized redness and bleeding, no suppuration, and moderate periodontitis. App't 1: 08/30/2013 At the first appointment, radiographs were taken and initial paperwork and data collection were started. Horizontal bite wings were taken but should have been vertical. It is still obvious moderate bone loss is present on the radiographs. All paperwork was completed with

the exception of full periodontal charting. I went over possibly using Biotene for her xerostomia for patient education and the use of an interdental brush for open contact areas. App't 2: Ms. Patient ran about 30 minutes late for her appointment and only plaque and bleeding indices were taken and maxillary quadrant perio charted. Patient kept falling asleep and a lot of time was lost trying to wake her up. A bite block was used but it did not help much while probing so this was time consuming and difficult. Patient education at this appointment was discussing further about her medications and the effects they had on her oral cavity, mainly xerostomia.

App't 3: At this appointment, plaque and bleeding indices were taken and full perio charting was completed with much difficulty. Once again, Ms. Patient kept falling asleep despite my best efforts to awaken her several times and request she turn her head (which kept falling to the side). I did have a bite block placed but it did not help. I had to request assistance from another student just to hold her head in place while she slept so I could get accurate readings on her charting. No patient education was done at this appointment (as Mrs. Brown is aware) because Ms. Patient was asleep for nearly all the appointment.

App't 4: At this appointment, plaque and bleeding scores were taken and I began patient education sessions. We went over her list of short and long term goals. I spoke to her about what plaque is and taught her the sulcular brushing method and demonstrated it on the typodont. I also had her show me in the mirror at the sink how to do it herself so I knew she understood fully. I explained the importance of brushing and why it was necessary to remove plaque. She said she would make the effort to brush at least twice per day. After patient education, I took her back to the chair and scaled her maxillary right quadrant with the ultrasonic machine and my hand instruments.

App't 5: At this appointment, plaque and bleeding scores were taken and I continued with patient education session #2. We reviewed her list of short and long term goals, plaque, and brushing. I explained to her that she had periodontal disease (and what it was) at a moderate level and used her X-rays to show her what it looked like in her own mouth. I went over the affects of diabetes and how it can be devastating to the periodontium, if not managed adequately. I taught her C-shape flossing method on the typodont and then had her repeat what she learned at the mirror on her own teeth. She stated she would attempt to floss at least once per day. After the session, I took her back to the chair and scaled her maxillary left quadrant with the ultrasonic and hand instruments. App't 6: At this appointment, plaque and bleeding scores were taken and I continued with patient education session # 3. We reviewed her list of short and long term goals, plaque, brushing, periodontitis, and flossing. I explained to her she currently had cavities that needed to be addressed so I pointed them out on her X-rays. I also showed her where she had previous restorations. I informed her she was a moderate to high risk for caries. I told her what a cavity was and how it forms on the teeth. I told her we would be doing a fluoride treatment on her teeth by the end of treatment and explained the benefits of fluoride. I recommended she try to limit cariogenic foods (explained what these were and what fermentable carbohydrates are), and suggested she add protein to her meals to raise the pH level of her saliva. After that, I briefly discussed the possibility of implants and the benefits it could have to her bone level. I ended our session and took her to the chair to ultrasonic and fine scale her mandibular right quadrant. App't 7: At this appointment, plaque and bleeding scores were taken, and I explained this was her final cleaning appointment this semester. I asked if she had started adding protein to her meals

and made any dietary changes. She said she did occasionally. I told her I would have her back in 2 weeks to place Arestin in any pockets she had greater than 5mm. I used the ultrasonic and then fine scaled her mandibular left quadrant. She had pain with this appointment so she got a LA w/o epi. I told her to rinse with warm saline water. I suggested she chew gum with Xylitol to cut her

caries risk. I did not have time to polish and do fluoride treatment so I will did that at the next appointment. App't 8: At this appointment, plaque and bleeding scores were taken, and I explained this was her final treatment appointment of the semester. I assessed her gingival condition and noted great improvement. I did full post periodontal charting on her and followed that will polishing and plaque-free. I then placed Arestin in those pockets 5mm or greater. Finally, did a fluoride varnish treatment on her since she was moderate to high risk for caries. She requested to come back sooner than her regular 6 month recall so she will return in mid-March 2014.
c. Plaque Index: Appt 1: 1 2: .2 3: .2 4: .63 5: 1.5 6: .6 7: .6 8: .6

d. Gingival Index: Initial .8%

Final .13% 5: 0% 6: 0% 7: 0% 8: 1%

e. Bleeding Index: Appt 1: 7.6% 2: 0% 3: 0% 4: 0%

f. Evaluation of Indices: 1. Initial: Plaque score taken was within a good range. Subsequent appointments have lowered below .5%. There are a few areas that have supragingival calculus but most is located subgingival. Gingival index was good and only very slight marginal bleeding was recorded on the first visit. None was noted on second and third appointments. Patient only flosses 2-3x weekly and does not always brush twice a day so this does not seem to be too bad but improvement is always possible. 2. Final: Ms. Patient has maintained a good plaque score at almost every appointment, with visit #5 being the highest at 1.5 and her bleeding score remained at 0% on scorable teeth until the very last appointment. She no longer has subgingival or supragingival calculus on her tooth surfaces. Ms. Patient has begun to floss nearly every day and started brushing 2x daily with the manual soft brush, the proxy brush and the end-tufted brush. At the last appointment she told me she had just purchased a powered toothbrush right before the appointment. I am hoping this also improves her plaque score in the future. g. Periodontal Chart: (Record Baseline and First Re-evaluation data) 1. Baseline: Ms. Patient has numerous areas of recession/attachment loss on the mandible and on the maxillary arch. She has class 1 furcation involvement on #15, #18, and #31. No suppuration is present but class one mobility is present on teeth 4-5, 8-11, 19, 21-24, 29, & 31. She has several pocket depths greater than 4mm located throughout her maxillary and mandibular arches. First evaluation: Ms. Patient generally has the same pocket depth readings and CALs as the first appointment because the recession does not change. I had difficulty probing her tissues the first time so many of the readings I had were off by a millimeter. However, at this appointment, I got much more accurate readings because she was able to stay awake during the procedure. She has a several pocket depths greater than 4mm. These deeper pockets range from 4mm-7mm. Due to the recession, her CALs are greater than normal. In some areas, they are very high. The largest numbers are: (7DL-5mm), (12DL-10mm), (13DL-5mm), (14DL-6mm), (15DL-8mm), (12DB7mm), (7DF-6mm), (19DL-6mm), (21DL-5mm), (26DL-5mm), (19DBmm-6/MB-5mm), and

(21DB-6mm).

5. Dental Examination: (caries, attrition, midline position, mal-relation of groups of teeth, occlusion, abfractions) Ms. Patient has two areas of concern for potential caries. The first is the distal of #14 and also the distal of #18, for which a referral may be necessary. Patient presents with moderate periodontitis as a result of multiple factors, including the presence of anaerobic bacteria, less than optimal oral hygiene, systemic diseases, and certain medications used to treat these diseases. All of her anterior teeth have pronounced attrition on both arches. She also has some anterior crowding and rotation with open contacts on nearly all her anterior teeth that arent crowded. There are also other open contact areas where teeth are missing. All these areas can be trouble spots for plaque retention and buildup.

6. Treatment Plan: (Include assessment of patient needs and education plan) App't 1: Initial data collection began and radiographs taken. Procedures done were: prerinse, head and neck examination, periodontal assessment, dental charting (minus perio charting), and plaque and bleeding scores taken. Patient education was done on how to treat xerostomia by using products like Biotene (sample given) and use of an interdental brush for open contact areas. App't 2: Retake of a right premolar bitewing was done. Plaque and bleeding indices were taken, prerinse was done, and the maxillary arch perio charting was completed. Patient education at this appointment consisted of how her medications were contributing to xerostomia and to try locating Biotene in a larger quantity that the sample given at the first appointment. App't 3: Medical/ dental history updated. Plaque and bleeding scores were taken, prerinse was done and full periodontal charting was completed. Gingival index was also completed at this appointment. No patient education was done because she slept through the entire appointment, regardless of my attempts to waken her. Mrs. Brown is aware of this as she had issues keeping her awake to probe, as well. App't 4: Patient Education Session #1, medical/dental history updates, prerinse, plaque and brushing will be discussed with the use of visual aids such as my flip chart, the typodont and various toothbrushes. Sulcular brushing will be suggested. Plaque and bleeding indices will be taken. Ultrasonic of the maxillary right quadrant will be done followed by fine scaling of the maxillary right quadrant. App't 5: Patient Education Session #2, medical/dental history updates, prerinse, plaque and brushing will be reviewed with the use of visual aids. New education topic will be on periodontitis and how

diabetes is a contributing factor for periodontitis, and flossing with use of the typodont, floss, and flip chart. C-shaped flossing will be taught. Plaque and bleeding indices will be taken. Ultrasonic of the maxillary left quadrant will be done followed by fine scaling of the maxillary left quadrant. App't 6: Patient education Session #3, medical/dental history updates, prerinse, using visual aids plaque and brushing will be reviewed, periodontitis and flossing will be reviewed and new education topic will be caries. Her radiographs will be shown to her with the areas of concern and she will be taught what causes caries. I will explain the benefits of fluoride treatment and therapy. I will also mention xylitol products as a method to stop growth of cavity causing bacteria. I will show her the root cavities she currently has on her bitewing radiographs. Plaque and bleeding indices will be done. Ultrasonic of the mandibular right quadrant will be done followed by fine scaling of the mandibular right quadrant. App't 7: Chairside patient education as needed, will continue with reviews of all the information previously taught. Medical/dental history updates, prerinse, plaque and bleeding scores taken. Ultrasonic of the mandibular left quadrant will be done followed by fine scaling of the mandibular left quadrant. App't 8: Medical/dental history updates, prerinse, plaque and bleeding scores taken, post evaluation of periodontal charting, reassessment of oral/gingival tissues and possible healing, Arestin will be placed in areas that have pocket depths greater than 5mm. Review will be done of long term goal. Recall appointment set up for 3 months. Patient will be given a list of referrals.

7. Radiographic Findings: (crown root ratio, root form, condition of interproximal bony crests, thickened lamina dura, calculus, and root resorption) Ms. Patient has moderate, horizontal bone loss in all four quadrants. She has vertical bone loss present on the mesial surface of #4. She has occlusal amalgam fillings located in teeth #s 5, 18, 19, 29, and 31. She has TCRs located in teeth #s 4, 12 and 13. Furcation involvement is visible on #31. She has possible suspicious areas on the distal root surfaces of #14 and #18. Findings agree with moderate periodontitis.

8. Journal Notes: (Record in detail the treatment provided, oral hygiene education, patient response, complications, improvements, diet recommendations, learning level, short and long term goals,

expectations, etc.) The progress notes should be written by appointment date.

See journal entries

9. Prognosis: (Based on attitude, age, number of teeth, systemic background, malocclusion, tooth morphology, periodontal examination, recare availability)

I believe Ms. Patient has a good prognosis for being a geriatric patient, at nearly 70 years old. She has already stabilized her periodontal disease and is very excited to have learned new information that will aid in her ability to maintain the teeth she still has remaining. She is only missing 3rd molars, #3, #20, and #30. Her diabetes is under control and this should help her immune system fight any infection she may develop in her periodontium. She may end up with some vertical bone loss in the future around the missing teeth so I mentioned briefly the possibility of implants or a partial to maintain the bone level during patient education session #3. Her periodontal tissues responded well to treatment and she had only very slight, localized bleeding at our last appointment. She said she will keep a constant recall schedule to continue optimal health of her oral cavity.
10. Supportive Therapy: Suggestions to patient regarding re-evaluation, referral, and recall schedule. (Note: Include date of recall appointment below.)

I suggested seeing Ms. Patient in the Spring of 2014 so I could re-evaluate her periodontal health and make sure she is still capable of optimum self-care. I will monitor all gingival pockets, especially the deeper pockets she has upon recall. I will alter treatment and education if she is falling behind in her self-care and make changes where necessary to improve it, if needed. She is on a 6 month recall but she requested to be seen in mid-March (no specific date yet because we dont have next years clinic schedule but she prefers early morning, Friday appointments so probably Friday, March 14th) because she is anxious to know what her changes have been. I suggested she see a general dentist to repair the root caries she has on D14 & D18. She was also referred to a periodontist. She has seen Dr. Burd in the past but at this time, her insurance will not cover a visit to him. She said she would check Medicare and Humana to see where she could go.
11. Assessment of Changes: (including plaque control, bleeding tendency, gingival health, probing depths)

Ms. Patient has done fairly well at maintaining a plaque score below 1% at nearly all of her appointments and I encouraged her to try the interdental brush, end-tufted brush and floss tape to clean those areas she had problems with so she could lower her score below .5%. Her bleeding score was at 0% nearly every appointment on scorable teeth. She did end her appointments with slight, localized bleeding on F25 & MD28. Her gingival health improved by her final appointment, as there was less bleeding than originally seen at the initial appointment. She did not really have a reduction in probing depths but she didnt seem to have any get deeper than what was initially recorded.

12. Patient Attitudes and Cooperation: Ms. Patient is such a good-natured, pleasant patient with a fantastic attitude about her oral health. She realizes, at 70 years of age, that she needs to do what she can to keep the teeth she has for the rest of her life. She understood just about everything I explained to her and those things she wasnt quite sure about, we went over more thoroughly. She took nearly every piece of advice I gave her and applied it to her oral self-care. She was given samples of Biotene and two additional proxy brushes that could help her better clean her teeth. She began to use those and I noticed improvement in subsequent appointments. There is very little she can do about her diabetes, other than maintain it but she can do so much with the information and oral aids given her, including dietary suggestions to cut back on fermentable carbohydrates that can lead to caries. She was more than willing to try all avenues to achieve a healthy mouth. 13. Personal Evaluation/Reaction to Experience: I thoroughly enjoyed spending time with Ms. Patient. Especially with her being a special need (medically compromised) patient. I learned a lot on how everything about a patient affects their oral health. I learned how to recognize clinically the effects diabetes has on someones periodontal health. I learned that medications, especially later in life, do cause significant xerostomia and have seen the effects in a patients mouth. It is amazing how positive some people can be about changing their oral health, right down to being willing to come 8 times just to improve their health and learn what can be done in the future to sustain it. I was also not too great at probing at the beginning of the semester but doing the full perio charting twice helped me so much. I feel much more confident in probing and reading recession. I also got to use the Glucometer for the first time in clinic on an actual patient. I believe I did fairly well in educating Ms. Patient and completing her treatment. I know there are many areas I can improve upon but I feel I wont know exactly what they are until I gain more knowledge and experience. Im looking forward to seeing her back in the Spring to assess her progress.