Professional Documents
Culture Documents
Assessment Findings
Asthma (low grade; inhaler only used in sports) ------------------- may cause xerostomia due to albuterol
Sinus problems -------------------------------------------------------------- none
Severe headaches/ migraines ------------------------------------------- grinding/ clenching teeth night; overworking tmj
Mesognathic------------------------------------------------------------------ None
X shaped scar from birth control implant on left arm ---------- None
Occlusal exam: class 1 on LT. & RT. Molar; LT. & RT. Canine ---- none
Planned Interventions
STG: ask patient what bruxism can cause and how to define bruxism and what can it cause 6 months
prevent the cause
Ask patient what they could use to help with
STG: educate patient on wearing a night guard at bruxism from progressing more attrition,
night and headache problems
Prognosis Explain your prognosis
Good Patient has a decent home health care, but the patient needs to be shown better flossing
techniques shown by clinician in order to reverse gingivitis to keep it from progressing.
Fair
Poor
Questionable
Hopeless
Appointment Plan
Appt Plan for Treatment Plan for Education, Counseling or Oral Hygiene
# Instruction
Periodebridement on UR & UL. Reduce plaque score from 1.6 to .5 by final appointment
1
Check plaque score (reduce .4)
Polish, floss, & fluoride Advise patient to use mouth guards at night to prevent
3 the progression of attrition, and headache problems.
Check plaque score (reduce .4)