I.

Assessment
a. 68 year old white male. 510 and weighs 168 pounds.
b. Medical: Currently under care for prostate cancer. Had hernia

repaired at VA hospital in November 2011. Current medications:

Finasteride, Fish Oil, Flomax, Multivitamins, PreviDent 5000

Sensitive Toothpaste, Testosterone, and Semorelin. No oral

effects or effects on dental treatment for any of the medications.

No allergies. Dental: Amalgam restorations on teeth 5, 12, 18,

30. Tooth #3 was extracted and replaced with a 3 unit PFM

bridge on 2-4. Tooth #14 was extracted and replaced with a 3

unit PFM bridge on 13-15. Pt has gold crown on #19. There is

tartar buildup on his bridge. Patient uses PreviDent toothpaste

for 2 minutes BID. Patient uses a spin brush and Colgate

toothpaste. He flosses twice a week.

c. Patient was in the Navy for 30 years. Likes to garden outside.

Does not smoke or drink alcohol.

d. Blood pressure- 122/82.
e. Extra Oral Examination- WNL. Intra Oral examination- Amalgam

tattoo on buccal mucosa by #18. Fordyce granules on lips and

buccal mucosa. Mandibular tori on right side. White coating on

tongue. Generalized abrasion. Attrition on 22-27. Plaque score-

32%. Class B calc. Description of the gingiva- generalized red,

generalized pointed interdental papilla, generalized rolled

marginal gingiva, generalized firm and resilient and stippled

gingiva.
 f. Periodontal case type- Generalized slight, localized moderate.

Generalized probing depths 2-4 mm except on LL where 5 and 6

mm were present.
g. Radiographs were not current so vertical bitewings were ordered

for 3/30/16. Bone level is healthy in all quadrants except LL

where there is localized bone loss. Mandibular third molars are

impacted.
II. DH Diagnosis
a. Moderate plaque, bleeding and calculus. Gingival recession and

furcation involvement are present. No mobility. Low caries risk.

b. Periodontal case type- Generalized slight, localized moderate.
III. Plan
a. Needs to be seen in OPER for #19 FGC caries and PERIO.
b. Want patient to brush twice daily with BASS technique. Floss

daily using bridge threader around both bridges. Want to see

plaque score reduced by next visit. Reduced probing depths in

the LL quadrant.
c. Phase 1- Oral hygiene instruction. I will talk about brushing,

flossing, and developing a routine. Phase 2- Scaling/root planing

all 4 quadrants by hand. Phase 3- Polish to remove stains with a

medium agent. Phase 4- Restorative work. Phase 5- 6 months

recall to evaluate progress.

IV. Implementation
a. Dr. Harris did a consultation. She found FGC distal root caries on

#19 and DMR fx lines on #18. Recommended Vitality floss action

for patient. I started with a disclosing solution showing patient

the areas that need improvement. For hand scaling, I used the

H5/33 sickle, 1/2, 11/12, and 13/14 Gracey. After I hand scaled, I
 polished with a medium grit agent. I flossed FM and

demonstrated how to use floss threaders and sent patient home

with a few. I demonstrated BASS brushing technique and C wrap

flossing. No fluoride necessary because patient is using

prescription strength fluoride toothpaste. Sent patient home with

floss threaders, soft tooth brush, floss and sensitivity tooth paste.

No anesthesia needed. No prescriptions needed.

V. Evaluation
a. At second appointment, I checked plaque score (which was

reduced) At the 6 month recall appointment I will check bleeding

index, probing depth, calculus amounts and plaque score to see

if reduced.
b. Chart probing depths, plaque and bleeding index.
c. Will continue use of vertical bitewings to measure bone loss.
d. At the second appointment the patient reported using the Vitality

toothbrush at night to break up the plaque and using floss

threaders around bridge area. At 6 months recall, perform plaque

score to evaluate improvement of brushing.

Wilkins, E. M. (1999). Clinical practice of the dental hygienist (11th ed.).

Philadelphia: Lippincott Williams & Wilkins.

Wynn, R. L., Meiller, T. F., & Crossley, H. L. (2014-2015). Drug information

handbook for dentistry: Including oral medicine for medically

compromised patients & specific oral conditions (20th ed.). Hudson,

OH: Lexicomp.