I.

Assessment
a. 44 year old Latino female. 52 and weighs 130 pounds.
b. No known medical problems. No allergies. Current medications: multivitamins

with no oral effects or effects on dental treatment. Teeth #1, 17, and 32 have been

extracted. Tooth #14 has been extracted and will be replaced with a 3 unit fixed

partial denture #13-15. Patient does not comply with recommended recare

appointment intervals. Patient reports dry mouth in mornings and grinding of

teeth.
c. Patient snacks between meals. Uses a medium bristled toothbrush twice daily with

a fast scrubbing motion. Flosses daily.

d. Blood Pressure 112/70. Normal and acceptable to continue with treatment.
e. Extra oral examination- WNL. Intra oral examination- generalized abrasion and

decalcification. Plaque index 17%. Generalized stippled, pink, spongy and

edematous gingiva with pointed interdental papilla. Generalized recession.

Generalized light extrinsic staining.

f. Perio case type- generalized slight localized moderate. Generalized probing

depths < 5mm. Localized probing depths: 6mm on mesial lingual and distal

lingual on tooth #31, 6mm on distal lingual on tooth #30, and 7mm distal facial

on tooth #31.
g. Radiographs- generalized horizontal bone loss.
II. DH Diagnosis
a. Patient is non compliant with recommended recare appointment intervals. This

contributes to her unhealthy oral hygiene regimen.

b. Perio case type- generalized slight localized moderate.
III. Plan
a. Needs to be seen in PROS for preparation, impression and framework for 3 unit

fixed partial denture #13-15.

b. Want patient to start using soft bristled toothbrush. Brush twice daily with BASS

technique. Continue flossing daily with C wrap technique. Want to see reduced

probing depths.
 c. Phase 1- oral hygiene instruction. Phase 2- scaling and root planing. Phase 3-

polishing and fluoride varnish. Phase 4- PROS for 3 unit fixed bridge. Phase 5- 6

month recall to evaluate progress.

IV. Implementation
a. Start with a disclosing solution to show patient the areas that need improvement.

OHI- we will demonstrate the BASS technique with a soft bristled toothbrush,

especially areas with recession and validate flossing with C wrap technique. Use

of area specific curettes and scalers. No anesthesia needed. No sensitivity. Polish

with a medium grit agent. Fluoride varnish chosen due to areas of recession.

Sending patient home with soft bristled toothbrush. No prescriptions needed.

V. Evaluation
a. At 6 month recall, we will check plaque score, probing depths, calculus amounts

and patient interview.

b. Chart probing depths and plaque score.
c. Update radiographs to vertical bitewings to measure bone loss.
d. Patient interview to check if patient is using a soft bristled toothbrush twice daily

and check if still flossing correctly. 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.