Kamesha McFadden

Periodontal Care Plan

Fall 2015

PERIODONTAL CARE PLAN

Patient Name No Name Age 35
Date of initial exam 8-25-15 Date completed 11-19-15
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.
Mrs. No Name is a 35 year old female who is 2 1/2 months pregnant (1 st trimester) and presents active
periodontitis. It is detrimental to her oral health, as well as has some effect on her baby, if she does not learn
about this disease and halt its progression. She describes her health as being good and says her last physical was
in 2005 with a general doctor. She is currently under the care of an OBGYN for her pregnancy care. A medical
release was required from her OBGYN concerning local anesthesia while still in her 1st trimester. Her OBGYN
gave us permission to take x-rays on this patient as long as there is a lead apron covering abdomen, give
anesthesia and to perform prophylaxis on this patient. She describes herself as being out of breath after walking a
block due to her pregnancy. Mrs. No Name presents sinus problems and acid reflux/GERD, but she isnt
currently taking any medications due to her pregnancy. However, Mrs. No Name mentioned that she has anemia,
and is taking her prenatal vitamins which contains iron. The following are contributors to the progression of Mrs.
No Name periodontitis: infrequent dental exams, calculus, untreated dental caries, improper oral hygiene
practices, clenching and grinding, and possible xerostomia. Frequent dental visits are important every 6 months
for optimal oral health, but in her case every 3-4 months because of her periodontal state. Calculus retention is a
major contributing factor of her periodontitis. It cannot be removed with a toothbrush; it has to be removed by a
professional. As the calculus remains on the tooth surface by a pellicle, it accumulates layers of plaque biofilm,
which irritates the gum tissue and cause it to pull away, causing gingival recession. The untreated dental caries
are retentive in which they can harbor more plaque accumulation resulting in periodontitis. Clenching and
grinding habits can be problematic resulting in alveolar bone resorption, which can lead to teeth mobility and
progress periodontitis. Improper oral care like not flossing and using medium to hard bristle tooth brushes can
contribute to periodontitis due to the inability of plaque reduction. Over time gram-negative anaerobic cocci,
gram-negative rods, and Porphyromonas gingivalis colonize in the plaque accumulation to cause periodontitis.
With all these factors contributing to her active periodontitis, it is important that this patient gets the proper oral
hygiene education and treatment to halt the progression of her periodontal disease.
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)
Mrs. No Name chief complaint is to get a deep cleaning and complains of cavities that are keeping her from fully
chewing up her food. Her last cleaning was in 2007 where she received a deep cleaning; however her most recent
dental visit was in February of 2015. At this appointment she only received x-rays, but shes unsure what kind of
x-rays she received. When tried to contact the dentist office that gave her care, we found out the facility was shut
down. She does not remember the name of the dentist seen. Mrs. No Name does not have a dentist due to having
no insurance; however, she does have Medicaid. I informed her that she can come here every 3-4 months for
routine cleanings since we do not take insurance and the fees are reasonable. To locate possible bone loss, carious
lesions and sub gingival calculus I will take a low dose digital radiograph of the patient teeth. No serious
problems were associated during previous treatment. Mrs. No Name currently does not like her teeth. She feels as
though her smile is ugly and looks gross due to the generalized recession and calculus build up. Every now and
then her gums will bleed when she brush or try to floss her teeth. This means she have active disease present. She
stated that she only brush once a day and rarely floss because the floss will not go in-between her teeth. For this
reason, the bleeding could be from not flossing regularly and not brushing twice a day to reduce the plaque
accumulation in her oral cavity. Patient complains of sensitivity to cold stuff which is common for someone with

Kamesha McFadden
Periodontal Care Plan
Fall 2015
generalized recession. The dentin anatomy is underneath enamel and is surrounded by gingival tissue; therefore,
it is extremely sensitive to touch, pressure, and temperature. Patient stated that she clenches and grinds in her
sleep, making periodontitis occur more rapidly. Teeth grinding, also known as bruxism, is a common condition
normally caused by stress and anxiety and often occurs during sleep. Mrs. No Name attrition could be a result of
this problem. I recommended buying a mouth guard to wear at night while sleeping to protect her enamel. She
noted that at her last dental appointment she had 4 cavities; however, she put that she only consumes less than 2-3
sugar containing drinks per week. Though this may be true, the fact that she has poor plaque control can be the
reasons for her caries. The sugars she does consume adhere to the plaque and began to demineralize the tooth. It
takes 20minutes for salvia to neutralize the ph balance of the oral cavity. Since Mrs. No Name stated that she
often have dry mouth, it probably takes twice as long to neutralize her oral cavity allowing the caries formation.
Dry mouth causes gingival tissues to dry out. The information provided on the risk assessment show that this
patient has a high risk for periodontal disease because she exhibit poor plaque control, lacks regular dental care,
radiographic loss of crestal bone, shows clinical recession, display bleeding upon probing, and presents bruxing.
She is also at high risk for caries because she has localized demineralization on the posteriors, lacks regular
dental care, had prior caries experience, reveals exposed root surfaces, exhibits poor oral hygiene, has a
decreased saliva flow, and presents bruxing. She was at a low risk for oral pathology. Mrs. No Name brushes
with a medium toothbrush and use crest complete with whitening toothpaste once a day in the mornings, allowing
the gram-negative cocci and gram rods to live and grow. This allows more time for plaque accumulation and
caries susceptibility to occur throughout the day and night. Mrs. No Name using the bass method; however, I
noticed that she does not angle her toothbrush at 45 degrees and she uses a lot of pressure when brushing. She
rinses every day, but she does not floss because she cannot get the floss to slide down in-between her teeth. When
I mentioned that a lot of her poor oral habits have a lot to do with her current periodontal state, she was eager to
learn more about her condition and ways to improve it. Because of this I said her learning level to be self
interest since she is willing and ready to improve her oral health for the better and halt her periodontitis. Using
the disclosing solution and showing her all the areas missed, really made an impact on Mrs. No Name. She could
not believe she was missing so many surfaces on her teeth. The diagnosis on this patient would be that she does
not have a dentist to visit regularly due to the fact that she does not have dental insurance and funds are currently
insufficient.

3. Oral Examination: (lesions noted, facial form, habits and awareness, consultation)
A head and neck examination was performed on Mrs. No Name. During this examination, extraorally, I
noted a 2mm macule on her left cheek etiology being developmental. She presented dry, chapped lips
etiology being sun exposure. I noticed a unilateral submandibular lymphadenopathy on the left side that
was non-tender etiology allergies. Intraorally, I noted a torus on the median palatine etiology being
developmental. White bilateral keratinized tissue was found on the buccal mucosa etiology being cheek
biting. She presents maxillary and mandibular exostosis etiology being developmental. Mandibular tori
were found near tooth numbers 21, 22, 28 and 29, as well as brown pigmentation on the left lateral
border of the tongue, both etiologies being developmental. Mrs. No Name grinds and clench in her
sleep, as well as mouth breathes. I mentioned that the clenching and grinding over time can cause TMJ
issues making it difficult for her to chew and can wear away her enamel. Clenching and bruxing are
parafunctional habits that can exert excessive force on the teeth and to the periodontium, causing more
rapid bone loss and pocket formation. Mouth breathing has a tendency to dry out the gingival tissues of
the anterior region, decreasing saliva flow, which buffers the pH balance. She tongue thrust the back of
her anteriors when she swallows. When this patient tongue thrust she exerts excessive lateral pressure
against her teeth which can be traumatic to the periodontium. Her occlusal classification shows that she
is a class III in the molar region and a class I on the canines. The overbite for this patient was 1mm
being within normal limits and her overjet was 2mm with a midline shift to the right by 1mm. No cross
bites or open bites were found. I informed my patient that cheek biting is not good for her tissue and can
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Kamesha McFadden
Periodontal Care Plan
Fall 2015
cause painful sores as well as mal-occlusion of the teeth.
4. Periodontal Examination: (color, contour, texture, consistency, etc.)
a. Case Classification VI Periodontal Case Type II
b. Gingival Description:
App't 1-8/25/15:
At this appointment, generalized flat gingival architecture was found. The color was generalized
redness of the gingival tissues, mainly in the areas of the papillae. The consistency was generalized
edematous/spongy. Margins were generalized rolled and thickened. No suppuration was present.
Surface texture of both the papillae and margins were generalized smooth and shiny; however, there
was localized smooth and shiny surface texture of the attached gingiva on the mandibular anteriors.
App't 2- 8/26/15:
On this appointment day, every description of the gingiva noted in appointment 1 was still the same.
No suppuration was present.
App't 3- 8/28/15:
Upon probing, I noticed a lot of bleeding in several areas of her mouth. The etiology of the bleeding
points could be due to the presence of bacteria in those areas causing the inflammation. The tissue
appeared redder on the mandibular facials than in the last two appointments. Her plaque score was
2.7 and her bleeding score was 3.4.
App't 4- 9/8/15:
During this appointment, I began periodontal charting the mandibular right quadrant. The presence
of bleeding was still noted in the indication spots and the consistency, margins, and surface texture
still remained the same. No suppuration was present. Because of pregnancy, her gingival tissue is
only going to get worse due to hormonal changes. Until there is a removal of the built up calculus,
the gingival tissue will remain red, and edematous, with a smooth and shiny surface texture. Her
plaque score increased by 0.1 and her bleeding score was a 3.2%.
App't 5- 9/18/15:
At this appointment, I got periodontal charting for the mandibular right quadrant complete. The all
quadrants except mandibular right were still red, rolled, edematous, and smooth and shiny. The
mandibular right; however, was not as inflamed as before due to previous ultrasonic scaling. Tissue
in this quadrant appears to have healed and is looking healthier. Her gingival still had rolled
surfaces, but they were not edematous. My patient plaque score decreased by .8 and her bleeding
score decreased by .5%. No suppuration was present.
App't 6- 10/9/15:
At this appointment, I completed periodontal charting the mandibular left quadrant. The mandibular
right quadrant showed much improvement. The papilla was scalloped, pink in color and stippled,
with rolled margins. The other 3 quadrants were still inflamed with redness, edematous tissues and
heavy bleeding. Her plaque score decreased by .3 and her bleeding score was 18%. No suppuration
was present.
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Kamesha McFadden
Periodontal Care Plan
Fall 2015
App't 7- 10/13/15:
At this appointment, I completed scaling the mandibular left quadrant. I am now noticing
improvement on the mandibular left quadrant. The papilla is appearing to be scalloped, slightly pink
in color and stippled with localized rolled margins along the posterior teeth. The maxillary arch is
still inflamed with edematous, smooth and shiny tissues, along with heavy bleeding when explored
and has localized dark red to purple color of the margins on the facial anteriors. Her plaque score
decreased by .5 and the bleeding score was 9%. No suppuration was present.
App't 8- 10/28/15:
At this appointment, I completed periodontal charting the maxillary right quadrant. This quadrant
was very inflamed with lots of bleeding. She had calculus build up along the facials of her anteriors
that you could visually see which was causing the gingival tissues to appear dark red to purplish in
color. However, the mandibular quadrants appear to look healthy and looks like the pocket depths
may have reduced due to the scalloped appearance and the gingival hugging the tooth surface. Her
plaque score increased by .3 and her bleeding score was 12%. No suppuration was present.
App't 9- 11/4/15:
At this appointment, I completed periodontal charting the maxillary left quadrant. I was very
pleased with the signs of improvement in the other 3 quadrants. The architecture of the 3 quadrants
was generalized scalloped, with less redness. Tissue in the maxillary left quadrant; however, was
still edematous, red, sensitive to touch and inflamed. All of her gingival tissues should show much
improvement at her post cal appointment since cleaning was completed at this appointment. Her
plaque score decreased by .3 and her bleeding score was 18%. No suppuration was present.
App't 10- 11/19/15:
This was Mrs. No Name post periodontal evaluation. I carefully examined the gingival tissues and
was very pleased with the amount of improvement that I saw in Mrs. No Names overall oral health.
My patient even noticed the scalloped, stippled appearance of her gingival tissues. Her architecture
was generalized scalloped and all quadrants seemed to be a health color, now a lighter pink except
for slight redness on the maxillary facial anteriors. The mandibular anterior areas were still slightly
sensitive, spongy, smooth and shiny with minimal bulbous papillae. Upon completion of full
periodontal charting, lots of improvement was noted with her pocket depths, tissue height, and
clinical attachment levels. Her gingival index improved from a 1.9 (fair) to 1.4 (fair) Her plaque
score increased by .8 and her bleeding score was 17%. No suppuration was present.
c. Plaque Index: Appt 1) N/A 2) N/A 3) 2.7 (poor) 4) 2.8 (poor) 5) 2.0 (poor) 6) 1.7 (fair) 7) 1.2 (fair)
8)1.5 (fair) 9)1.2 (fair) 10) 2.0 (poor)
d.Gingival Index: Initial 1.9 (Fair)

Final 1.4 (Fair)

e. Bleeding Index: Appt 1) N/A 2) N/A 3) 3.4 % 4) 3.7% 5) 0.5% 6) 18% 7) 9% 8) 12% 9)18% 10) 17%
f. Evaluation of Indices:
1. Initial evaluation
Plaque scores for first 3 appointments of doing a plaque score were poor, 2.7, 2.8, and 2.0; however, my

Kamesha McFadden
Periodontal Care Plan
Fall 2015
patient indicated that she brushes not long before the start of her appointment. The presence of this
bacterium plays a major role in the progression of periodontitis. The area noted with the most plaque
accumulation was on the anterior facials due to lack of consistent overlapping strokes. Because of the
plaque retention and the calculus build up it is also the area with the most recession. Her improper
plaque biofilm control can result in direct damage to gingival tissues causing alterations to the natural
contour of her tissues. Infrequent dental visits, and improper oral hygiene practices are the main cause
for the buildup in these areas; therefore, after educating the patient on how to brush and floss properly,
and stressing the importance of oral maintenance, these tissues should begin to heal and halt the
progression of periodontitis. Initially, Mrs. No Names gingival index was 1.9 (fair) relating to the
plaque and calculus build up over time. Her bleeding indices for the first 3 appointments of doing a
bleeding score were 3.4%, 3.7%, 0.5%.
2. Final evaluation

My patient CALs had decreased significantly leaving only one area of 4mm on the facial of
#24. Because my patient has not been compliant with her flossing habits, her prognosis is
currently fair; however with decreased pocket depths and the start of habitual flossing will put
her prognosis as good. My patient had managed to keep her plaque score consistent at fair, but
then it decreased to poor at her final appointment, showing no improvement in her oral hygiene
practices. Her bleeding score fluctuated throughout the duration of treatment ending at 17%.
With proper flossing techniques her bleeding and plaque score could have significantly been
lowered, which could aid in halting disease progression. Mrs. No Name final gingival index
decrease by .5, fair. This shows some improvement from her initial gingival index, but there is
still slight inflammation on the maxillary anteriors present.
g. Periodontal Chart: (Record Baseline and First Re-evaluation data)
1. Baseline:
Upon probing, there were (42) generalized 4mm pockets, (24) generalized 5mm pockets, six (2D, 5D,
18DL, 19DL, 20DL, 31D) 6mm pockets and one (18D) 7mm pockets found. Clinical attachment levels
showed nine (29B, 28B, 24B, 18DF&L, 19DL and 23L) 4mm localized on the mandible. This shows
that there is a severe need for proper techniques and education on oral hygiene. The deepest pocket
depth of 7mm was found on the disto-facial surface of number 18. The presence of these pockets
increase the attraction of both anaerobic and aerobic bacteria, and allows in food particles and plaque
accumulation, resulting in gingival inflammation. No suppuration was present. Generalized redness
appeared especially in the marginal areas. No x-rays have been taken at the moment until patient 2 nd
trimester; however I feel like my patient will have moderate horizontal bone loss due to loss of
attachment levels and clinical recession. Clinical recession was found on teeth numbers 28 and 29
facial, 22 lingual, 26 lingual, and 23, 24,25 facial and lingual. Recession was greatest on the lingual of
number 24. Sensitivity is likely to occur after cleaning. Sensitivity to percussion was noted on numbers
5 and 29. No furcation involvement was noted. Thus far, Mrs. No Name has 3 areas in the mandibular
right quadrant where her clinical attachment levels were a 4 on the buccal of numbers of numbers 28
and 29 and distal of number 31. This is unhealthy because she is only 1mm away from being into the
furcation area on the distal of number 31.
2. First evaluation:
At the first evaluation, there are still 4-5mm pocket depths; however, major improvement was seen and
only one 6mm pocket depth was found at this evaluation. There were (39) generalized 4mm pockets, (7)
generalized 5mm pockets, and (1) localized 6mm pocket depth on 18DL. No 7mm pocket depths were
found at this evaluation and the 7mm pocket depth at the baseline evaluation improved to 5mm. Clinical
attachment levels showed (1) localized 4mm attachment on 24F. This improvement can possibly be
contributed to NSPT. A host of the 4mm and 5mm pockets now where 5mm and 6mm pocket depths at

Kamesha McFadden
Periodontal Care Plan
Fall 2015
the baseline. A majority of the 4mm pocket depths at the baseline has now decreased to 2mm and 3mm
pocket depths. The 4mm and 5mm pockets that are currently present are on 11D, 22D, and the posteriors
of the maxillary and mandibular arches. Mrs. No Name should pay close attention and properly remove
the plaque biofilm in these areas in order to move forward with decreasing these pocket depths as much
as possible. As with the baseline evaluation, there was no suppuration present at this evaluation. As a
clinician, I was pleased to see the improvements in the overall gingival health of my patient and her
excitement as she saw the improvements herself. There was slight generalized bleeding on probing at this
evaluation. Several areas of recession are still present in the mandibular anterior area, contributing to
sensitivity that the patient often experiences when brushing and drinking cold beverages. Because several
pocket depths were reduced, her clinical attachment levels improved in the areas that were most
significant. Tissue heights were also improved. There was still sensitivity to percussion on numbers 5,
12, 21, and 29. Class 1 furcation was still noted on #3 and no mobility was present.
5. Dental Examination: (caries, attrition, midline position, mal-relation of groups of teeth, occlusion,
abfractions)
During the dental exam tooth number 3, 15, and 32 had occlusal suspicious areas. Untreated decay can leave
holes which can harbor periodontal pathogens allowing them to grow, undisturbed by self-care efforts.
Sealants are needed on tooth numbers 2,4,5,12,13,14,18,19,20,21,28,29,30,and 31. Attrition was noted on all
the mandibular and maxillary teeth due to patient habitual clenching and grinding. These parafunctional

habits that can exert excessive force on the teeth and to the periodontium, causing more rapid bone
loss and pocket formation. Diastimas where found between numbers 5 and 6, 6 and 7, 7 and 8, 8 and 9, 9
and 10, 10 and 11, 11 and 12, 23 and 24, 24, and 25, and 25 and 26. There was a slight 1mm midline shift to
the right. No open bites or cross bites were found. Molar relationships were a class 3 and the canine
relationships were a class 1. Localized demineralization was found on the posteriors and there were
generalized hypocalcification, mostly on the maxillary anteriors. Numbers 17 and 32 is mesially impacted.
Numbers 1 and 16 is unerupted. Numbers 6 and 11 were mesially torsiverted. No abfractions were found.

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

App't 1-8/25/15:
Mrs. No Name was scheduled for 4 hours this appointment. This patient was new to our clinic so she
had to fill out the Statement of release, HIPPA, Patient Practice, and Medical/Dental history forms.
Upon reviewing her medical history I noticed that she was pregnant and still within her first trimester.
Before I was to go any further I asked my clinic instructors Mrs. Tornwall and Mrs. Brown if it was ok
for me to treat this patient within her first trimester. Since she wasnt far from being in the second
trimester they went ahead and approved my patient. I proceeded reviewing her medical/dental history
and began taking her vitals. After vitals I was able to get her paperwork signed by my pod instructor. I
place the napkin on my patient, allowed her to pre-rinse, and gave her safety glasses. I began the head
and neck exam, periodontal assessment, and the dental charting. I was only able to complete the head
and neck exam paperwork during this appointment. X-rays was not taken at this appointment because
my patient is still in her first trimester. Patient education discussed at this appointment was brushing her
3rd molars. I informed her of the importance of getting all the way back there and brushing those molars
because she has active carious lesions on the occlusal of number 32 as well as on her 2nd molar number
15. Learning level this day was self-interest. Her next appointment was scheduled this day.
App't 2- 8/26/15:
Mrs. No Name came for a 2 hour appointment on this day. We updated her medical/dental history, took
vitals and allowed her to pre-rinse. I then was able to finish up her periodontal assessment and dental
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Kamesha McFadden
Periodontal Care Plan
Fall 2015
charting this day; however I only had enough time to get to get the periodontal assessment checked. At
this time Mrs. DeMoss classed my patient as a VI and we estimated her to be a case 2, due to her
recession and the lack of x-rays. At this appointment I explained the importance of flossing her 3rd
molars. Learning level was self-interest. Her next appointment was scheduled this day.
App't 3-8/28/15:
Mrs. No Name came for another 4 hour appointment today. During this appointment, I updated her
medical/dental history, recorded her vitals, and had her to pre-rinse. The head and neck examination as
well as the dental charting was checked at this appointment. Dr. Porter mentioned that she needs all of
her 3rd molars extracted, especially the one with the suspicious area. When I asked about sealants he
mentioned numbers 2,4,5,12,13,14,18,19,20,21,28,29,30, and 32. I was able to complete her risk
assessment as well the informed consent. Once all my paperwork was completed and signed I allowed
my patient to brush at the sink using a soft bristle toothbrush and paste. After brushing, I painted my
patient teeth with disclosing solution and allowed her to see the purple areas she missed. I stated purple
because she had build up plaque accumulation on the interproximal surfaces of her teeth. I informed my
patient that these are the areas she misses every time she brush and that she really needs to floss these
areas to remove the plaque. She mentioned that she does not floss because she cannot get the floss in
between her teeth. I recommended that she use wax coated floss to get to those areas by C-shaping
the floss and she agreed to give it a try. After getting a plaque score I was ready to start her ultrasonic
procedure. Because my patient is still in her 1st trimester, I had to get a medical release from her doctor
before any anesthesia or treatment could be continued. Once her OBGYN gave approval of all
procedures, I then asked my patient if she would be interested in being my periodontal patient since she
qualified. Learning level was self-interest. Her next appointment was scheduled this day.
App't 4-9/8/15:
Today was a 4 hour appointment for Mrs. No Name. I updated her medical/dental history, allowed her
to pre-rinse, brush at the sink and took a plaque score (2.8). Mrs. No Name showed no improvement in
her plaque score. Once I recorded her plaque score I obtained her gingival index, which was a 1.9 (fair)
with heavy bleeding on #3F, 9D, 12D, 19D, 25D, 28M&D. Her bleeding score increased by .3%. While
trying to take intraoral pictures, I experienced some technical difficulties with the computer. Once the
problem was resolved, I then were able to take 3 (mandibular facial/lingual anteriors, and full smile)
intraoral pictures of Mrs. No Name teeth. My patient mentioned that she has been eating starchy foods
like baked potatoes and crackers every day because of her pregnancy cravings. I told her that she needs
to eat more nutritious foods because it is better for her baby as well her oral health. I also mentioned
that these foods are starch and contain sugar, and is very retentive, which can cause more cavities in her
mouth. When I began periodontal charting on the mandibular right quadrant, I noticed that I could not
feel her CEJ due to calculus build up. To get an accurate reading with the probe, I informed Dr.
Williams that I would need local anesthetic for my patient. He told me to apply 20% benzocaine topical
anesthetic over the area of the inferior alveolar nerve, so that he could give 4% Septocaine (with
epinephrine 1-100,000x1.7mL). After the local anesthetic set in, I was able to being scaling the
mandibular right quadrant using the ultrasonic scaler. Neither the periodontal charting nor the ultrasonic
scaling was checked this day I informed my patient to start flossing with the waxed floss now that I
have removed some of the heavy calculus. Learning level was self interest. Her next appointment was
scheduled this day.
App't 5- 9/18/15:
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Kamesha McFadden
Periodontal Care Plan
Fall 2015
Today was a 4 hour appointment. I updated Mrs. No Name medical/dental history, allowed her to prerinse, brush at the sink and get a plaque score and bleeding score. Her plaque score was a 2.0 which
decreased by .8 and her bleeding score was 0.5%. After applying 20% benzocaine topical anesthetic
over the area of the inferior alveolar nerve, I then informed Dr. Porter to administer local anesthetic and
we used 2% Lidocaine HCL (with epinephrine 1-100,000x1.7mL) on the mandibular right quadrant. I
continued ultrasonic scaling the mandibular right quadrant and got it checked by Mrs. Dorsey. Once that
was completed, I got my periodontal charting checked and prepared for my first patient education
session over plaque and brushing. I reviewed all her goals and taught her all she needed to know about
plaque and how it forms into calculus. During this time, her intraoral pictures were presented to provide
a visual of plaque and calculus build up on her teeth. I demonstrated on the typodont the Stillmans
method (because of her generalized recession) and allow her to demonstrate on the typodont as well as
on her own teeth. I helped her remove the surfaces she left behind, and reflected on what she learned
about plaque and brushing. We concluded our session by previewing goals for session two. After the
session, I began fine scaling the mandibular right quadrant; however I was not able to get it checked
because of time. Patient learning level was self-interest. Her next appointment was scheduled this day.
App't 6- 10/9/15:
This appointment was scheduled for 4 hours. I updated Mrs. No Name medical/dental history, allowed
her to pre-rinse, brush at the sink, and got a plaque and bleeding score. Her plaque score at this
appointment was a 1.7 (fair) which decreased by .3 and her bleeding score was 18%. I finished scaling
her mandibular right quadrant and got it checked. Once checked off, I got the DDS to administer 3%
Mepivicaine HCL, with no epinephrine x 1.7ml using a 30 short needle on the mandibular left quadrant.
Once the anesthetic had settled in I began ultrasonic scaling, had the quadrant checked and completed
periodontal charting. We did not have time to start our second patient education session at this
appointment. Her next appointment was scheduled this day. The learning level for this appointment was
involvement. I told my patient to angle her brush while she was brushing to get the areas around the
gum line that she had been missing. She told me that she has started using the Stillmans method, but
still trying to get used to it, and she has also started flossing when she remembers to do so.
App't 7- 10/13/15:
Mrs. No Name came for another 4 hour appointment. Her medical/dental history was updated, I had her
to pre-rinse, brush her teeth at the sink, and got a plaque and bleeding score. Her plaque score was 1.2
(fair) decreasing by .5 and her bleeding score was 9%. This appointment started out with patient
education session two, due to the fact that there was no time left at the last appointment. During this
session I went over all her goal and mentioned all the goals that she has obtained thus far. Our topic was
about Periodontitis, what is it, how it is caused, and how to halt it? The skill was flossing and I
demonstrated how to properly floss different areas in the mouth, C shaping the floss in the
interproximal spaces cuffing the tooth on the typodont. Mrs. No Name mentioned not being able to slip
the floss in between her teeth, so I will recommend Glide floss by Oral B. After Mrs. No Name
demonstrated how to floss on the typodont, I allowed her to practice the floss procedures at the sink as
well as review the modified Stillmans method to see if we needed to modify her technique. After
disclosing and getting areas that were missed, we reviewed what she learned about periodontitis and
flossing and previewed our final session. Once our session was completed, I began and completed fine
scaling the mandibular left quadrant and had it checked twice. Her next appointment was scheduled this
day. The learning level for this appointment was involvement.
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Kamesha McFadden
Periodontal Care Plan
Fall 2015
Appt 8- 10/28/15:
Mrs. No Name came for a 4 hour appointment. I updated her medical/dental history, allowed her to prerinse, had her to brush her teeth at the sink, and got a plaque and bleeding score. Her plaque score was
1.5 (fair) increasing by .3 and her bleeding score was 12%. I then had the DDS to give 4% Septaciane
HCL with epinephrine 3.4mLx 1:100,000 using a 30 short needle on the maxillary right quadrant. I
completed and had the ultrasonic and the periodontal charting checked. We then had our last patient
education session. During this session, all of Mrs. No Name goals were repeated as well as the goals she
has obtained. I discussed the caries process (how it is caused, what happens if not treated) and the
importance of Fluoride prevention, as well as ways she can find a dentist who can remove or fill the
teeth with suspicious areas (32, 1, 17, and 16). We reviewed the brushing and flossing, and she
demonstrated the techniques at the sink. I encouraged her to keep up with what she learned during the
sessions and reassured her that I am here to help her in any way that I can in improving her oral health. I
gave her contact information on the Dental clinic at UT in Houston for further dental treatment for her
caries and informed her of her three month recall appointment in February. I thanked her for her time
and asked if there were any questions. I completed fine scaling on the maxillary right quadrant, and had
it checked twice by the instructors. Her next appointment was scheduled this day. The learning level for
this appointment was involvement.
Appt 9- 11/4/15:
This was Mrs. No Name last cleaning appointment. She was scheduled for a 2 1/2 hour appointment. I
updated her medical/dental history, allowed her to pre-rinse, had her to brush her teeth at the sink, and
got a plaque and bleeding score. Her plaque score was 1.2 (fair) decreasing by .3 and her bleeding score
was 18%. I had the DDS to give her local anesthetic to begin ultrasonic scaling the maxillary left
quadrant. After ultrasonic scaling I will get it checked, as well as my periodontal charting, and began
fine scaling the quadrant. I was able to complete scaling the quadrant and had it checked twice;
however, I was unable to get it my spot check completed. Patient education discussed at this
appointment was her to demonstrate the brushing method at the sink, continuing to work towards our
goal of reducing her plaque and bleeding score. Because of dry mouth, Xerostomia and its effects was
discussed and the ways to reduce these effects by rinsing daily with biotene, chewing xylitol gum, and
sugarless lozenges. The learning level for this appointment was taking action. I informed my patient
that she will need to come back in 2 weeks for a post periodontal/calculus appointment at this time is
when we scheduled her appointment.
App't 10-11/19/15:
This was Mrs. No Name post periodontal/calculus visit. She was scheduled for a 4 hours appointment. I
updated her medical/dental history, allowed her to pre-rinse, had her to brush her teeth at the sink,
before getting a plaque and bleeding score, I obtained a final gingival index (1.4 fair). Afterwards, I
obtained a plaque score of 2 (poor) and a bleeding score of 17%. I then began periodontal charting all
four quadrants, as well as exploring and removing any excess calculus as well as a previous spot left
from the last appointment, and had it checked. I was then able to plaque free my patient, and completed
sealants on #30, 30, 18, and 19 and got it checked by the DDS. Arestin was not placed in my patients
periodontal pockets because she is pregnant and it contains Minocycline, which is a Tetracycline.
Tetracycline is can discolor the developing babys teeth, so to avoid that possibility we did not apply the
topical antibiotic. I applied the Fluoride varnish on her teeth, and gave her the instructions to not brush,
eat or drink anything crunchy, or extremely hot or cold for 4-6 hours and told her that the Fluoride was
going to make her teeth stronger. I stressed the importance of her 3 month recall which we will have
9

Kamesha McFadden
Periodontal Care Plan
Fall 2015
next semester (February 2016) at her maintenance appointment as well as finding a local dentist to get
her fillings. I encouraged her to start using the brushing and flossing method I taught her and make it
her goal to still show improvements at her maintenance appointment next semester. I re-demonstrated
how to floss and angle her tooth brush on the typodont, and allowed her to practice in her mouth one
more time. The learning level for this appointment declined to self-interest because my patient has not
been compliant with her flossing.
7. Radiographic Findings: (crown root ratio, root form, condition of interproximal bony crests,
thickened lamina dura, calculus, and root resorption)
Mrs. No Name vertical bitewing radiographs showed generalized, slight, horizontal bone loss. The
radiographs presented no restorations. Without restorations, the occlusal tooth surfaces develop deep
grooves which can house plaque biofilm. This biofilm become undisturbed causing it to mature and
eventually be colonized by gram-negative anaerobic cocci and gram-negative rods, which are known to
cause periodontitis. Calculus was present on 5M and D, 6M and D, 30D, 31D, 22D, 18M and D, 19D
and 14D. Generalized horizontal bone loss would be due to the presence of calculus build up in these
areas over time without proper removal. It is important to remove these deposits so that periodontitis
cannot be overemphasized. Suspicious areas were noted on 32M, 30M, 21M, 17M, and 18D. These
suspicious areas could cause a periapical abscess if not treated soon resulting in more bone loss. The
suspicious areas can also harbor periodontal pathogens allowing them to continue growing.
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.

8/25/15: This was Mrs. No Names first appointment. She arrived 1 hour and 45 minutes late. I
stressed the importance of making it to her appointments on time because that gives me cancellation
time that can affect my grade in the end. She explained to me that she has to put her daughter on the bus
in the mornings, she needed to grab breakfast on the way here, and had a hard time finding the clinic
and finding a park once she got here. While reviewing her medical and dental history I noticed my
patient was pregnant and still in her first trimester. She stated she still had another 4 weeks before she
would be in her second trimester. I discussed this over with Mrs. Brown and received an ok to continue
treatment on her. The patient stated that she had x-rays taken on her back in February, but it was in
Houston and she didnt remember the name of the office or the dentist. She made a phone call to a
relative that lives in Houston to drive by the location to get the information, but found out that the office
is no longer in service. Patient education discussed at this appointment was brushing her 3rd molars. I
informed her of the importance of getting all the way back there and brushing those molars because she
has active carious lesions on the occlusal of number 32 as well as on her 2nd molar number 15. Learning
level this day was self-interest.
8/26/15: Mrs. No Name came for a 2 hour appointment on this day. She was on time today
considering it was an evening appointment. She mentioned to me that her pregnancy cravings have been
jalepenos, crackers, and ice chips. Her craving of ice chips (pagophagia) are a result of pica that is
common in pregnant women of low-income. I told her that after I finish cleaning her teeth shell have to
avoid spicy foods until her gums heal enough for her to tolerate it because spicy food will irritate her
gingival tissue. I told her that the ice can cause wear on the enamel and could chip or break her teeth,
causing dentin to expose, making her teeth sensitive. She was understanding and stated that it will be
10

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Periodontal Care Plan
Fall 2015
something that she will try to improve. My patient was classed a VI, and possible case 2 this day. I told
my patient what a class VI case 2 meant and that she has periodontitis. This made my patient eager to
learn more about ways to improve her oral health. I told her that I was going to help improve her
condition, but I could not do it alone, she would have to do her part with the proper oral hygiene care.
At this appointment I explained the importance of flossing her 3rd molars. Learning level was selfinterest.
8/28/15: Mrs. No Name came for another 4 hour appointment today. She was 20 minutes late today
and explained to me that morning appointments; shell be at least 25 minutes late due to putting her
daughter on the school bus. While brushing, I noticed that she was using the Bass method, but she was
not angling her toothbrush at 45 degrees to get beneath the gingival pockets. I demonstrated how she
should angle her brush to get under the areas she was missing. She never knew that she had to get the
bristles under the tissue. I told her that bacteria can harbor underneath there even though she cannot see
it. When asked what type of toothbrush she uses, she stated that she uses a medium bristle brush. I told
her that soft bristle brushes are what she should be using because medium to hard bristle brush can
cause recession, and is not effective at removing the plaque. My patient told me that she only brush
once in the mornings and not at night. I stressed the importance of brushing twice a day as well as
flossing daily, which she stated that she does not do. She mentioned that she does not floss because she
cannot get the floss in between her teeth. I recommended that she use wax coated floss to get to those
areas by C-shaping the floss and she agreed to give it a try. This patient use mouth rinse daily after
she brush, and gets fluoride from her rinse and crest paste. When Dr. Porter came to give her local
anesthesia and learning that she was a pregnant patient, he hesitated and asked Mr. Brown about getting
a medical release from my patient OBGYN before going any further. Mrs. No Name and I reached out
to her OBGYN and had the medical release faxed to the facility. We waited an hour before we received
the medical release back, because of technical difficulties with the fax machine in Mrs. Woods office.
We finally received confirmation from her doctor stating that elective procedures can be performed
during all trimesters, x-rays can be done but patient MUST wear a LEAD SHIELD, Antibiotics are
recommended and patient has no allergies to penicillin or Cephalosproins, Tylenol or Tylenol #3 may be
given for pain, but no aspirin, and local anesthetics are preferred over IV sedation. Due to not enough
time to start the ultrasonic procedure, I asked Mrs. No Name if she would be interested in being my
periodontal patient for the semester, since she qualified and I havent began scaling on her yet. She
immediately said she would do anything to help, and also liked the fact that she would get to learn more
about her disease through our patient education sessions. Learning level was self-interest.
9/8/15: Today was a 4 hour appointment for Mrs. No Name. While trying to take intraoral pictures, I
experienced some technical difficulties with the computer. I informed Mrs. Brown and she had the I.T.
guys to come fix the problem so my pictures would save to the computer. My patient mentioned that she
has been eating starchy foods like baked potatoes and crackers every day because of her pregnancy
cravings. I told her that she needs to eat more nutritious foods because it is better for her baby as well
her oral health. I also mentioned that these foods are starch and contain sugar, and is very retentive,
which can cause more cavities in her mouth. Mrs. No Name was not aware of that the foods she is
craving can lead to more cavities because she said the foods are not sweet. After explaining more she
got a better understanding. I informed my patient to start flossing with the waxed floss now that I have
removed some of the heavy calculus. Learning level was self interest.
9/18/15: Today was a 4 hour appointment for Mrs. No Name. She arrived on time today and stated
that her husband was able to put her daughter on the bus. We discussed x-rays but pt mentioned she
would feel more comfortable taking them during her 2nd trimester, which will be in a few months. Our
first patient education session was today over plaque and brushing. I reviewed all her goals and taught
11

Kamesha McFadden
Periodontal Care Plan
Fall 2015
her all she needed to know about plaque and how it forms into calculus. During this time, her intraoral
pictures were presented to provide a visual of plaque and calculus build up on her teeth. I demonstrated
on the typodont the Stillmans method (because of her generalized recession) and allow her to
demonstrate on the typodont as well as on her own teeth. I told her the importance of brushing for 2
minutes and also showed her how to brush her tongue, and told her that plaque can accumulate there as
well. I helped her remove the surfaces she left behind, and reflected on what she learned about plaque
and brushing. We concluded our session by reviewing our session and previewing our topics for session
two. Patient learning level was self-interest.
10/9/15: Today was a 4 hour appointment for Mrs. No Name. She arrived 10 minutes late. Mrs. No
Name is now in her 2nd trimester and came on October 8th for standard bitewing radiographs. I was not
able to do an FMX on my patient because the DDS mentioned that I can only do that if it is an
emergency situation. At our 4 hour appointment, she stated that she has started flossing, but not every
day. She mentioned that she has not gotten in the habit of using the Modified Stillmans method, but she
is trying. While she was brushing I noticed that she was not angling her brush, missing the areas along
the margins, especially on the lingual surfaces. Other than that; however, my patient feels confident that
she is doing better with the effectiveness of her brushing based on her plaque score improvement. We
were not able to do session two of patient education this day, and both agreed that we will pick up first
thing at our next appointment. Patient learning level was involvement.
10/13/15: Today was another 4 hour appointment for Mrs. No Name. She arrived 7 minutes late. We
started with our second patient education session was today over Periodontitis and flossing. I reviewed
all her goals and taught her all she needed to know about Periodontitis and how she could halt it by
flossing daily using the C shaped method. Her intraoral pictures as well as her radiographs were
presented to provide a visual of the recession and bone loss. I demonstrated on the typodont the flossing
method and allow her to demonstrate on the typodont as well as on her own teeth at the sink. I told her
the importance of getting her floss all the way to the back, getting her wisdom teeth. I told her to think
of flossing her teeth as shining/waxing shoes moving the floss back and forth. If done correctly, the
friction of the floss against the tooth surface should make a squeak noise (according to Dr. Byrd). I
helped her remove the surfaces she left behind, and reflected on what she learned about Periodontitis
and flossing. We concluded our session by reviewing our session and previewing our topics for session
three. My patient stated that she has been feeling sensitivity on #21. When air or my explorer touched
the surface of the tooth, she would feel lots of pain. She suspected a cavity, but I explained to her that
this could be as a result of exposed root surfaces from previously using the ultrasonic on that quadrant.
She was extremely sensitive on the mandibular left quadrant and needed two doses of Septocaine
anesthetic. Patient learning level was involvement.
10/28/15: Today was another 4 hour appointment for Mrs. No Name. She arrived 7 minutes late.
Last week we had to reschedule her appointment that was scheduled for 10/20/15 because she had strep
throat over the weekend and went to the ER. Patient was put on amoxicillin and had completed her
treatment. Later that week my patient mentioned that she had a stomach virus and was put on Tylenol 3
and had been taking it for pain as needed; however, at the time of her appointment she had not taken the
medication for the day. We then had our last patient education session today. During this session, all of
Mrs. No Name goals were repeated as well as the goals she has obtained. I discussed the caries process
(how it is caused, what happens if not treated) and the importance of Fluoride prevention, as well as
ways she can find a dentist who can remove the teeth with suspicious areas (32, 1, 17, and 16). We
reviewed the brushing and flossing, and she demonstrated the techniques at the sink. I encouraged her
to keep up with what she learned during the sessions and reassured her that I am here to help her in any
way that I can in improving her oral health. I gave her contact information on the Dental clinic at UT in
12

Kamesha McFadden
Periodontal Care Plan
Fall 2015
Houston for further dental treatment for her caries and informed her of her three month recall
appointment in February. I thanked her for her time and asked if there were any questions. My patient
began complaining about itching under her nose which was from the numbness of the anesthesia. I
reassured her that it was just the local anesthesia and it would wear off. Mrs. No Name, has frequent
restroom breaks due to her pregnancy. She went a total of 5 times during her appointment which
consumes a lot of time. I stressed to her the importance of her coming to her next appointment in order
for me to have 2 weeks to get her back in for her post cal appointment. Patient learning level was
involvement.
11/04/15: On this day Mrs. No Name was scheduled for a 2 hour appointment; however, I had to
switch appointment times with my other patient for her, because she was waiting for her husband to
come pick her up. Unsure of how long that was going to take and preventing from getting a lot of
cancellation time, I was able to get my 3:30 patient to come in at 2 instead, which made me have 1 hour
and 40 minutes to finish Mrs. No Name. When Mrs. No Name arrived, I was able to finish her last
quadrant; however, we ran out of time for me to complete a spot check on the quadrant. We discussed
completing this at our last appointment. Patient education discussed at this appointment was her to
demonstrate the brushing method at the sink, continuing to work towards our goal of reducing her
plaque and bleeding score. Because of dry mouth, Xerostomia and its effects was discussed and the
ways to reduce these effects by rinsing daily with biotene, chewing xylitol gum, and sugarless lozenges.
Patient stated that she will start chewing the xylitol gum as an alternative. Patient learning level was
taking action.
11/19/15: Today Mrs. No Name was scheduled for a 4 hour post calculus/post periodontal
appointment. She arrived on time today. Although her gingival tissue looked healthier than before, Mrs.
No Name mentioned that she has not been flossing, because of that her plaque score had increased. She
stated that her daughter unravels the dental floss that she had at home and have not bought anymore to
floss, so I gave her two packs of floss at this appointment. I re-demonstrated how to floss and angle her
tooth brush on the typodont, and allowed her to practice in her mouth one more time. I stressed the
importance of her using her brushing and flossing techniques effectively and told her that it was her
goal to have good results when she comes back in 3 months for her maintenance appointment. She
stated that she would start using the methods I taught her because she does not want her mouth to be as
bad as it was and that she now understand the importance in maintaining good oral health. I motivated
her to make it her goal to show improvements at her maintenance appointment next semester. Arestin
was not placed in my patients 5mm pockets because she is pregnant and Arestin can have adverse
affects on her developing baby. My patient mentioned that food was still getting caught in the grooves
of her mandibular molars, so sealants were placed on 30, 31, 18, and 19. After Fluoride varnish
application I gave her the instructions to not brush, eat or drink anything crunchy, or extremely hot or
cold for 4-6 hours and told her that the Fluoride was going to make her teeth stronger. I stressed the
importance of her 3 month recall which we will have next semester (February 2016) at her maintenance
appointment as well as finding a local dentist to get her fillings and possible extractions. The learning
level for this appointment declined to self-interest because my patient has not been compliant with her
flossing.
9. Prognosis: (Based on attitude, age, number of teeth, systemic background, malocclusion, tooth morphology,
periodontal examination, recare availability)

Based on my patients attitude and cooperation towards treatment, I feel that Mrs. No Name prognosis
would be fair because she has to push herself to continue with her oral hygiene practices. I stressed the
13

Kamesha McFadden
Periodontal Care Plan
Fall 2015
importance of maintaining good oral health because the bacteria she leaves in her mouth can affect her
baby, and that made an impact on her. She is slowly making progress, but I can see her determination
and her drive to eventually get better and not only for her baby but for herself as well. Now that Mrs.
No Name has been educated on periodontitis and what to do to halt it, she does not want to make her
condition worse and she is really pleased with the results she have received from the treatment. It has
allowed her to feel more confident in her smile. At this time Mrs. No Name has 30 teeth, with #1 and 16
being un-erupted. Her occlusion molar relationship is a class III on the right and left and canine
relationship is a class I on the right and left. Her overbite (1mm) and overjet (2mm) was within normal
limits with a midline shift 1mm to the right. There were no problems associated with tooth morphology.
The periodontal exam showed significant improvements in the reduction pocket depths and clinical
attachment levels. Re-care availability is good since she understands the importance of maintenance
care. Mrs. No Name has no background of systemic disease, which could contribute to the progression
of periodontitis.
10. Supportive Therapy: Suggestions to patient regarding re-evaluation, referral, and recall schedule. (Note:
Include date of recall appointment below.)

By her final evaluation, Mrs. No Name made a slight effort to improve her oral health. She consistently
maintained a lower plaque score than her initial appointment up until her post calculus appointment,
where it increased; however, we were not able to reach our goal of 0.5 by the end of treatment. With this
being said, she has areas where she will need to improve. Her response to the treatment was positive,
showing on her last appointment, a major difference in the health of her gingival tissues. She was even
able to tell that some improvements were accomplished and she was very pleased. I suggested that Mrs.
No Name be referred to a dentist for fillings or removal needed on (32, 1, 17, and 16). Because of active
periodontitis, her history of poor oral hygiene and infrequent dental exams, I have placed Mrs. No
Name on a 3 month recall. Her recall appointment should be in February 2016.
11. Assessment of Changes: (including plaque control, bleeding tendency, gingival health, probing depths)

For the duration of treatment, Mrs. No Name maintained fair plaque control up until her last
appointment, which declined back to poor. By lowering her plaque control from poor to fair, can help
halt the progression of her periodontal disease; however, better oral hygiene habits need to be practiced
to significantly lower her chances of progression. By increasing her plaque score from a 1.2 to a 2 can
cause further destruction of the periodontium. Mrs. No Name bleeding tendency has been reduced due
to calculus removal and consistent self care. Based on the examination at the final evaluation
appointment, my patients gingival health has improved significantly. There was less inflammation and
pocket depths and clinical attachment levels were reduced since the bacteria were lessened and
inflammation had decreased.
12. Patient Attitudes and Cooperation:
My patient attitude towards treatment was avid. Mrs. No Name was a dedicated patient and was always
interested in learning more about ways to improve her oral health. Even though she was very eager to
learn, it took her a while to cooperate and get in the habit of doing the practices. I empathized with my
patient because I know what it is like trying to get into the habit of doing something that has never been
done before, it is not easy. Mrs. No Name showed her determination to improve her oral health as she
listened and seemed generally interested each patient education session. Each appointment, my patient
14

Kamesha McFadden
Periodontal Care Plan
Fall 2015
was eager to know if she was progressing and how I felt she was doing with putting her new skills to
use based on what was shown clinically. Although there was not a significant improvement in her oral
hygiene practices, it was evident that she was trying to do better and that is what really matters. Overall,
I am pleased with Mrs. No Names determination to improve her oral health and I will continue to
motivate her to better her practices until she reaches an optimal oral health.
13. Personal Evaluation/Reaction to Experience:
Evaluating myself on a personal level, I would say that I now feel assured in taking on bigger tasks in
private practice. Before taking on the task of completing a class 6 patient I was a little unsure of myself
in being able to accomplish it because I did not know what to expect. Now that I have completed my
periodontal patient, I have gained confidence in myself that I can do anything that I put my mind to. I
am now positive that I can give proper treatment to patients with periodontitis and motivate them to
endeavor for optimal oral health. My reaction to this experience is progressed, because I feel like I am
progressing in the role of a productive hygienist. Being able to educate, motivate, and improve the oral
health of my patients and have them notice their improvement makes my heart smile. The fact that I am
able to make a difference in my patient lives and allow them to feel better about themselves and their
smile make me feel like I have done my job. I could not be more ardent about getting out in the real
world of hygiene practice and helping others improve the status of their oral and overall health. I am
grateful for the experiences I am getting in dental hygiene school.

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Kamesha McFadden
Periodontal Care Plan
Fall 2015

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