I.

Assessment
a. 58 year old white female. 56 and weighs 190 pounds.
b. Medical: Currently under care for diabetes and hypertension. Her

last A1C was 7.9. She reported eating right before the

appointment. She is taking medication for maintenance of a

stent placed in her upper left arm. She is also being treated for

fibromyalgia and neuropathy due to diabetes. Patient has had a

tonsillectomy, thyroidectomy, hysterectomy, cholecystectomy,

bladder lift, and ovarian cyst removal. Current medications:

Acetaminophen, Aspirin, Flexeril, Gabapentin, Glimepiride,

Levothyroxine, Metformin, Metoprolol, Plavix, and Tramadol.

Metformin can cause taste disorder and xerostomia. Tramadol

can cause xerostomia. Gabapentin can also cause xerostomia

and a dry throat. The others have no dental effects. Patient has a

reported allergy to Cipro. Dental: patient is missing teeth #1, 2,

16, 17, 18, 20, 30, and 32. She is scheduled for extraction of #3-

15 and #19, 29 and 31 and removal of palatal tori. She is

scheduled to get a complete upper denture and a lower RPD.

Patient uses a medium toothbrush and Colgate toothpaste. She

flosses occasionally. Patient is a high caries risk. She has

generalized rampant decay/root tips present on her maxillary

arch. Patient has posterior decay and root tips present on

mandibular molars.
c. Patient has a few special needs implications. She is a type 2

diabetic, a heavy tobacco smoker, and has benign hypertension.

d. Patient has her daughter and 4 grandchildren living with her. She

is very busy taking care of them. She likes to be outside and go

to the racetrack. Patient smokes one pack a day and drinks

alcohol occasionally. She is interested in quitting smoking.

e. Blood pressure was taken at 9:00 and it was 165/95. Patient had

not taken her medication for high blood pressure this morning. I

advised patient to take it, we then waited 20 minutes and took

again. It was- 140/89.

f. Extra Oral Examination- bilateral clicking in jaw. Intra Oral

examination- palatal tori, stomatitis, coating on tongue. Attrition

on 23-25. Medium yellow generalized staining. Class 1 occlusion

left. Was not able to detect occlusion on right because of missing

teeth. Overjet 3 mm. Severe overbite. Class B calc. Plaque score

25%. Description of the gingiva- generalized red, generalized

blunted interdental papilla, generalized knife-edged gingiva with

localized recession, generalized firm and resilient and stippled

gingiva.
g. Periodontal case type- Generalized slight. Generalized probing

depths in the mandibular <4 mm. Did not probe maxillary as

patient is scheduled for extraction.

h. Patients with diabetes have an increased risk of caries and

periodontal disease. This combined with her poor oral hygiene

accounts for the caries and perio disease. Some of her

medications for diabetes cause dry mouth. This makes it so that

the pH of the saliva is not adequate. Because she is a heavy

 smoker, she has stomatitis. For hypertension, there are no oral

implications, we just need to make sure blood pressure is

adequate to treat the patient.

i. Radiographs current. Generalized 2-3 mm from the CEJ.
II. DH Diagnosis
a. Moderate plaque, bleeding and calculus. Gingival recession and

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

b. Periodontal case type- Generalized slight. High caries risk.

Patients with diabetes have a higher risk of periodontal disease

and caries.
III. Plan
a. Patient needs a consultation in PROS and a screening in Oral

Surgery.
b. Want patient to brush twice daily with BASS technique and floss

daily. Want to see plaque score reduced by next visit. Want her to

quit smoking so she will be able to maintain the health of the

complete and partial dentures and overall oral health.

c. Phase 1- Oral hygiene instruction. Discuss brushing, flossing, and

developing a routine. Phase 2- Ultrasonic on remaining

mandibular teeth and finish with fine scale. Deplaque maxillary

arch. Phase 3- Polish to remove stains with a medium agent.

Phase 4- Apply fluoride varnish. Phase 5- Restorative work and

oral surgery. Phase 6- 6 month recall to evaluate progress.

IV. Implementation
a. I started with a disclosing solution showing patient the areas that

need improvement. I used the ultrasonic scaler on the

mandibular arch. 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. I demonstrated BASS brushing

technique and C wrap flossing. Fluoride varnish was given

because patient has rampant decay and some sensitivity. Sent

patient home with a soft tooth brush, floss and sensitivity tooth

paste. No anesthesia needed. No prescriptions needed.

b. I gave patient Biotene for the dry mouth due to the medications

she was on.

V. Evaluation
a. At next appointment, I will check plaque score. At the 6 month

recall appointment I will check bleeding index, probing depths,

calculus amounts and plaque score to see if reduced.

b. Chart probing depths, plaque and bleeding index.
c. Patient will need radiographs 1-2 years from 4/04/16.
d. At 6 months recall, perform plaque score to evaluate

improvement of brushing. See if patient is flossing more regularly

and using the BASS technique.

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.