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Natalie Mick

Treatment plan for Mr. R.

I.

Assessment
a. Mr. R. is a friendly, talkative 57 year old male coming in for a cleaning and to
repair a broken filling. He is interested in a complete or partial denture for the
maxillary arch. He is allergic to codeine, oxycodone, and Darvon. The
patient suffers from hypertension, osteoarthritis, rheumatoid arthritis, tremors,
depression, and alcoholism. He takes Antabuse, Propanolol, Trazadone, and
Salsalate. Has not had a cleaning for around 20 years. Patient states he
brushes with Sensodyne and flosses daily, and also carries around a toothpick
to keep his mouth clean. Previous smoking and chewing tobacco habit, but
says that he quit 25 years ago. He has sensitivity to hot and cold, dry mouth,
and is aware that he grinds his teeth.
b. Patient is currently on medication to control alcoholism, but had an
overwhelming alcohol odor. Snacks on cheese, oranges, and chips.
c. Blood pressure: 132/80.
d. Extra-oral: Scar beneath left nostril due to melanoma excision. Intra-oral:
Bilateral mandibular tori and exostosis. Generalized attrition, severe on
maxillary anteriors. Interdental papilla is generally blunted. Heavy plaque.
e. Generalized 2-3mm probing depths with some bleeding on mandibular
molars.
f. Complete mouth series radiographs show attrition and decay, along with some

II.

bone loss in mandibular anteriors and UL quadrant.


DH diagnosis

a. Patient is in moderate to poor health. Has several ailments and medications,


along with poor oral health. Was hospitalized in February for a hairline

III.

fracture on right ankle.


b. Moderate periodontitis
Plan
a. Consultation needed by dentist to assess any possible caries and to restore
broken filling. Patient should also be seen by a prosthodontist for consultation
for possible denture.
b. Treatment goals are to prevent periodontal disease from progressing further
and to educate the patient how to take care of their teeth and mouth in order to
achieve that goal.
c. Phase I: Calculus and plaque removed. Phase II: Not needed. Phase III: Not
addressed at this time. Phase IV: Patient set up for a recall appointment in 6

IV.

months.
Implementation
a. The patients full mouth was hand-scaled. Anesthesia was not needed because
patient tolerated treatment well. I then polished the entire mouth with fine
prophy paste, flossed, and administered fluoride varnish. The patient had a
plaque score of 45% so proper brushing technique was shown along with

V.

demonstration of proper flossing on typodont.


Evaluation
a. After scaling, I used an explorer to check for any remaining calculus. After
polishing, I disclosed the patients teeth to check for any residual plaque.
b. Probing depths will be evaluated at next appointment to ensure that
periodontal pockets have not increased. Plaque score will also be evaluated to
see if patients oral hygiene has improved.
c. Radiographs will not need to be made at the next appointment since the CMS
was made in January 2015. New radiographs would only be made if the
patient presented with any new symptoms or pain.

d. I do not expect the patients oral hygiene to improve greatly. He is adamant


that he brushes and flosses daily and keeps his mouth clean, but his plaque
score and my overall evaluation say otherwise.

Clark, S. (2015). Dental Hygiene II, Kirkwood Community College.


Wilkins, Esther M. (2013). Clinical Practice of the Dental Hygienist. Philadelphia, PA:
Lippincott Williams & Wilkins.