Periodontal Care Plan Part 2

Patient: Cindy Bollman

Student: Leslie Coleman
Periodontology (DHYG 1311) Fall 2017
Mrs. DeMoss
Patient Name: Cindy Bollman Age: 60
Date of Initial Exam: October 5, 2017 Date Completed: November 30, 2017

PHASE I

1. Medical History: (systemic conditions altering treatment, pre-medication, medical clearance)

explain steps to be taken to minimize or avoid occurrence, effect on dental hygiene diagnosis
and/or care.
Cindy was diagnosed with Osteoporosis in 1997, but currently does not take any
medications for it. Osteoporosis can cause periodontitis to be more progressive because of the
low mineral bone density. Cindy was diagnosed with Arthritis in 1987 and fibromyalgia in 1989,
she takes over the counter medications when she experiences episodes. There is a link between
periodontitis and arthritis due to the inflammatory process. Cindy has suffered from the
autoimmune disease Lupus, in the past, but is currently in a state of remission. Lupus can
contribute to periodontitis because of the destruction of connective tissue throughout the body.
Cindy is in remission for Raynauds syndrome, but occasionally has flair ups. Raynauds
phenomena causes contraction of the small vessels which could potentially lead to loss of
attached gingival and gingival recession, followed by widening of the PDL space. Cindy also
suffers from Sjogrens syndrome, which causes xerostomia. This dry mouth could potentially
lead to increased number of caries and tooth loss. Cindy has been diagnosed with bronchitis in
the past, last in April of 2017, she reports that it is seasonal and tends to happen a few times a
year, this should have no effect on her periodontitis. Cindy also has seasonal sinus problems and
asthma, for which she used the brew inhaler, she states that she does not need a rescue inhaler.
Cindy was diagnosed with Type II Diabetes in 1997, she takes Metformin, Trajenta, Lantus
insulin, Novolog flexpen insulin and regularly monitors her blood glucose. As a diabetic she is
more at risk of periodontitis because diabetics are more susceptible to infection and have delayed
wound healing. Cindy was diagnosed with GERD in 1991 which she controls with over the
counter medication, a couple times a month depending on the meal she has eaten. If her GERD is
not well controlled it could contribute to her periodontal disease by allowing stomach acids to
break down her tooth surface. Cindy experiences severe headaches and migraines that she treats
with OTC medication. Cindy will sometimes have a cold sore outbreak because of her weakened
immune system, the last outbreak was in November of 2016 which she treated with aciclovear.
Cindy has experienced high blood pressure in the past, it has been more normal since she has lost
weight. However she also takes spironolactone, which can contribute to dry mouth and a semi
supine chair position in GI side effect occur. This is the reason it is so important to check her
blood pressure at the beginning of each appointment. I will have a baseline in order to know if
her blood pressure starts off normal . If it is high then I would ask Cindy how she felt and if she
had taken her medication the day. If she has not yet taken her medication, I would request that
she took it at that time.
Cindy also takes a daily Aspirin and multivitamin. She takes atrovastain calcium a
cholesterol-lower agent which makes it important to consider a semi supine chair position if GI
side effects occur. Cindy takes gabapentin an analgesic, loratadine an antihistamine, estrodiol as
an estrogen supplement and setraline as an anti-depressant, which makes it important to
encourage effective oral hygiene to prevent soft tissue inflammation and use caution with oral
hygiene aids to prevent injury. When chronic dry mouth occurs I should advise her to, avoid
mouth rinses with alcohol, use daily home fluoride product for antiquaries effect chew sugar free
gum, take frequent sips of water or use saliva substitutes. Her four antidiabetic medications make
it necessary to monitor vital signs at every appointment, be prepared to manage episodes of
hypoglycemia, asses salivary flow as a factor in caries, periodontal disease and candidiasis, and
place on frequent recall to evaluate healing response.
Cindy has had surgeries to remove a benign growth in her right breast. Rotator Cuff
surgery on her left shoulder, ankle surgery to remove a benign giant cell tumor. She has had two
colonoscopies with a total of 10 benign polyps being removed. She had half of her thyroid
removed for a benign tumor. Scar tissue removed from her left ankle. A total hysterectomy for a
benign mass. Her surgeries have no had an affect on her periodontal disease.
Cindy is allergic to the antibiotic Erythromycin, it causes severe hives and extreme
itching. This is important to know because if she needs an antibiotic medication the doctor will
know not to prescribe Erythromycin.

2. Dental History: (past dental disease, response to treatment, attitudes, dental I.Q., chief
complaint, present oral hygiene habits, effects on dental hygiene diagnosis and/or care)
Cindys reason for visit is wanting to have her teeth cleaned. Her last dental visit was
February 2016, where she had a tooth extraction with no cleaning. She also visited the LIT dental
hygiene program in April 2017 for a set of bitewing radiographs. Cindys regular dentist was
effected by hurricane Harvery and the office is currently closed.
Cindys teeth are sometimes sensitive to cold and pressure while she brushes her teeth. Pressure
sensitivity is most likely due to her periodontal disease and the loss of tooth structure and bone
loss. Losing bone and structure makes a tooth less stable and more mobile which can make teeth
sensitive to pressure. The cold sensitivity can also be because of her periodontal and/or the
suspicious area she has on the occlusal surface of #18. More of the cementum and dentin are
exposed due to loss of gingival mucosa and since there is blood and nerve supply, the tooth will
be more sensitive cold. Halting the periodontitis and doing fluoride treatments are important in
helping to reduce the sensitivity of Cindys teeth. Cindy has had cavities in the past when
visiting her DDS, which she has had repaired with both amalgam and tooth colored restorations.
Cindy says that she experiences dry mouth at different times, which can contribute to periodontal
disease by not allowing plaque and bacterial to be washed away from the tooth surface by saliva.
Allowing this debris to further mineralize into calculus and then contribute to bone remodeling.
Cindy is aware of the importance of oral care to her overall health. Together we can halt the
progression of her periodontal disease and use recall, maintenance appointments to keep it from
becoming active again.

3. Oral Examination: (lesions noted, facial form, habits and awareness, consultation)
Cindy wears glasses which has no effect on her oral care or oral health. This is a developmental
issue that will continue to deteriorate with age. Cindy had partial thyroidectomy ten years ago for
a benign tumor, her remaining thyroid gland functions normally, as determined by her PCP.
Cindy has xerostomia due to Sjorgens syndrome and her medications, this can increase the
severity of periodontitis. She does practice mouth breathing during times she is effected by
seasonal allergies, which can affect her dry mouth.

4. Periodontal Examination: (color, contour, texture, consistency, etc.)

a. Case Classification: Prophy Class 4 Periodontal Case Type: Case 3
b. Gingival Description:
Appointment 1: This was Cindys initial exam so I examined all quadrants in her mouth.
The color of her marginal, and attached gingiva was normal in every quadrant. The color of her
free gingival was red on the entire mandibular arch. Teeth 22-27 have an endematous/spongy
consistency with rolled margins on # 26 and blunted papillae on the facial aspect. There is no
suppuration. The papillary and marginal gingiva are smooth on the maxilla, while they are
smooth and shiny on the mandible. The surface texture of the attached gingiva is stippled on the
maxillary facial and smooth and shiny on the mandibular arch.
Appointment 2: Rolled margins on the maxillary lingual surfaces with slight bleeding on
probing. Mandibular arch appears to be red, endematous and spongy. Attached gingival is
smooth and shiny on mandibular arch and stippled on the maxillary arch. The papillary and
marginal gingiva are smooth on the maxilla, while they are smooth and shiny on the mandible.
Appointment 3: Mandibular arch still red, endematous and spongy with rolled margins
especially notable on the lingual surface of #20 and facial surface of #35. Maxillary right -
gingiva appears firm and pink. Maxillary left a brighter more flouresent pink. Attached
gingival is smooth and shiny on mandibular arch and stippled on the maxillary arch. The
papillary and marginal gingiva are smooth on the maxilla, while they are smooth and shiny on
the mandible.
Appointment 4: Maxillary left gingival is slightly red, endematous and spongy when
compared to the three quadrants that have already been treated. Attached gingival is smooth and
shiny on mandibular arch and stippled on the maxillary arch. Papillary and marginal gingival are
smooth on both arches.
Appointment 5: Gingiva in all four quadrants appears firm and pink. No bleeding on
probing. Attached gingival is smooth and shiny on mandibular arch and stippled on the maxillary
arch. Papillary and marginal gingival are smooth on both arches.
c. Plaque Index:
Appt 1 - 1.3 Good
2 - 0.6 Good
3 - 0.5 Good
4 - 0.3 Good
5 0.16 Good
d. Gingival Index: Initial 0.25 Final - 0
e. Bleeding Index: Appt 1- 3.47% 2 - 2.7% 3 - 2.7% 4 - 1.3% 5 0%
f. Evaluation of Indices:
 1. Initial Cindys Plaque index is 1.3-Good. There was moderate plaque on the buccal
surface of the UR sextant, and slight plaque on the facial UA and LA sextants as well as the
lingual surface of the LL sextant. There was no plaque on the UL and LR sextants. The presence
of plaque can lead to periodontitis by mineralizing into calculus and then causing bone
remodeling in the area. Cindys initial gingival index is 0.25 which is good. All areas on teeth #
12, 19, 25 and 28 exhibited no inflammation. The mesial, facial, and distal of # 3 showed mild
inflammation. While the lingual surface of #3 (#2) showed moderate inflammation. #9 only
exhibited mild inflammation of the distal surface. Cindys bleeding index is 3.47% and was
found on the facial surfaces of #s 2, 4, 9, 15 and the lingual surface of #2. Bleeding is an
indication of infection.
2. Final Cindys plaque index at her final appointment is 0.16-Good. Plaque remained
on the lingual surface of # 30. Cindys brushing skills became more refined during her visits.
She began to use more of a 45 degree angle and was able to achieve more thorough plaque
removal. While I did my part removing subgingival deposits and Cindy did her part to maintain
her at home oral hygiene, we worked together to improve her overall gingival and periodontal
health. There was no inflammation present on the teeth evaluated for gingival index.
g. Periodontal Charting: (Record Baseline and First Re-Evaluation data)
1. Baseline PD 4 on lingodistal of #2, 5 on palatodistal #30, 5 on palatodistal and
palitomesial #31 and 4 on faciodistal #31. The gingival margin was 1mm apical to the CEJ on
the facial surface of teeth #s 5, 12, 14 and 20. There is no suppuration or furcation involvement.
Cindy is missing all third molars and teeth # 3, 13, 19, and 29. Amalgam restorations on DO #12,
and DO, MO #14. Slight attrition on teeth 8, 9, 11, 24, and 25. Suspicious areas O. #18,
Localized moderate horizontal bone, loss and loss of crestal lamina dura between 12-13 and 19-
20 radiographically. All of this shows Cindys periodontal disease. Bone loss, loss of soft tissue
structure, recession, teeth malposition and having deep pockets are all the definition of
periodontitis.
2. First Re-Evaluation -
There was a 3mm decrease on D 31, a 2mm decrease on D 3, a 2mm increase on D/DL 18 and
DL 2. There was a 1mm increase on MD 23, 24, 25, D 20, MLD 28, L 27, ML 18, ML 20,
DF/ML 2, DF 9, 10 M 11, F12, M/D/L/ML 14, DL 4 L 10, 11. There was a 1 mm decrease on L
20, 21, ML/DL 23, MLD #24, MD #21, F26, M27, D 30, 31, F 5, 6, FM 7, D 11, M 12, F 15, DL
15, ML/DL 6, ML 8, L 19, ML 12. The areas where there was a decrease in periodontal probe
depth experienced healing. While the areas with an increase in probe depth must have been
previously blocked by a piece of calculus inhibiting my ability to take a true measurement.

5. Dental Examination: (caries, attrition, midline position, mal-relation of groups of teeth,

occlusion, abfractions)
Cindy has slight attrition on teeth 24, and 25, most likely because her age. The attrition has
developed over time as a result of everyday wearing of her teeth. The dentist states she has a
carious lesion on O18. Caries break down the tooth structure as the bacteria and acid and plaque
eat away at it. Her mandible lies 1mm to the left of her maxilla, creating a 1mm midline shift.
Cindy has a class I occlusion in left and right side canines, while her molars are unclassafiable.
Lingoversion # 24, 25, and 27 with labioversion on #26, which will most likely accumulate more
plaque. Her overbite and overjet both measure in at 4mm, which do not contribute to the
periodontal disease.
6. Treatment Plan: (Include assessment of patient needs and education plan)

Appointment 1
This appointment was used to do an initial assessment on Cindy to gather a baseline of her
periodontal condition. This information will be used to evaluate her periodontal disease status at
the end of treatment. It was also used to explain what will be asked of her as the perio patient in
order for me to meet the requirements for this semester. The dentist and I both talked to Cindy
about the carious lesion on the occlusal surface of #18 and the pain she is experiencing in this
area. We also filled out a referral for her to take to her DDS and have this repaired. Cindy and I
discussed how her health conditions and medications contribute to her dry mouth. The dentist
and I both recommend using salivary substitutes. I also mentioned that her health conditions
could be a contributing factor to her periodontal disease.

Appointment 2
1. Patient education: Brushing and Plaque
A. Use typodont to demo correct brushing
 B. Use patient education flip book to define plaque and explain how brushing helps
remove food debris and plaque from the gingival margin which is important to help halt the
progression of periodontal disease.
C. Have Cindy repeat what she heard and demo on her teeth at the sink.
2. Discuss short and long term goals to make sure we are on the same page.
Goal 1: Brushing habits
a. get a childrens soft bristle toothbrush and start using for hard to reach areas (short term)
b. reduce plaque score by 0.3 each visit (short-term)
c. Final plaque score of zero (long-term)
3. Intra oral Pictures
4. Plaque index and bleeding index
5. Full periodontal charting on UR quadrant
6. Fine scale UR quadrant

Appointment 3
1. Assess Gingiva
2. Patient Education: Periodontitis and flossing
A. Use patient education flip book as aid to define and explain periodontitis. Irreversible
gum disease that started as gingivitis, inflammation of the gingiva, to loss of tooth structure and
bone and progressed to periodontitis. Disease can be halted by good home care and frequent
recall. Use typodont to demonstrate correct flossing technique.
B. Have Cindy repeat what she heard
C. Discuss brushing again briefly and discuss any questions
Goal 2: Flossing
a. reduce bleeding score by 0.5% each visit (short term)
b. use the correct technique for flossing making a c shape with the floss on either side of the
tooth (short-term)
c. reduce plaque score to 0% by recall appoitment (long-term)
3. Plaque index and bleeding index
4. Ultrasonic mandibular arch with anesthetic
5. Full periodontal charting on mandibular arch
6. Fine scale mandibular arch

Appointment 4
1. Assess gingiva
2. Patient Education: Caries and fluoride supplementation
A. Use patient education flip book as aid to define and explain caries. Cavity or hole in
tooth caused by bacteria that comes from plaque, white filmy material on teeth. Plaque converts
sugars into acids which start breaking down tooth structure. May or may not have pain. Brushing
and flossing daily will keep caries away. Eat less carbs and sugars and fluoride treatment.
Fluoride helps remineralize teeth.
B. Have Cindy repeat what she heard
C. Discuss taking care of the carious lesion she has by making appointment with dentist.
Goal 3: Caries
a. make an appointment to have carious lesion on the occlusal surface of #18 filled (short-term)
b. have carious lesion fixed by recall visit in Spring(long-term)
c. return for a recall visit in four months rather than six to help hault the progression of
periodontitis (long-term) in March of 2018.
3. Plaque index and bleeding index
4. Ultrasonic UL quadrant with anesthetic
5. Full periodontal charting on UL quadrant
6. Fine scale UL quadrant

Appointment 5
1. Assess gingiva in lower and UL quadrants, plaque and bleeding index
2. Patient Education: Go over brushing, plaque, flossing, periodontitis, and caries. Discuss short
and long term goals. Answer any questions Cindy may have.
3. Ultrasonic UR quadrant with anesthetic
4. Full periodontal charting on UR quadrant
5. Fine scale UR quadrant
6. Polish all four quadrants
7. Plaque free
8. Fluoride treatment

Appointment 6
1. Final evaluation of gingiva with final gingiva index
2. Discuss goals again
3. Schedule recall appointment

7. Radiographic Findings: (crown root ratio, root form, condition of interproximal bony crests,
thickened lamina dura, calculus, and root resorption)
Moderate horizontal bone loss with loss of the crestal lamina dura between teeth 12-13 and 19-
20. Adverse crown to root ratio #6, #12. Root anomalies #2, #4; dilaceration. Periodontitis
involves bone loss around the teeth.

8. Journal Notes:
10/5/17
Reviewed medical and dental history, blood glucose 92mg/dl. Had patient pre-rinse with zero
alcohol mouthwash. Performed head, neck and intramural exam as well as periodontal
assesment. Took FMX to check bone levels. Perio case type 3. Used benzocaine on mandibular
left. Dental charted with x-rays. Plaque score 1.3 - Good, Bleeding score 3.47%, gingival index
0.25 good. Informed consent and risk assessment. Patient education - Xerostomia as a result of
medications and systemic disease, Suggested the use of salivary substitutes. LL: Awareness.
Patient was previously classed as a prophy class 4 during a screening appointment.

10/26/17
Reviewed and updated medical/dental history. Blood glucose 270 mg/dl. Went to the doctors
office on Monday for a steroid injection to treat poison ivy. As a result she has had elevated
bloody glucose. She had a cold sore break out ten days ago and had to miss her appointment a
week ago. She took acyclovir and the lesion has since resolved. As a result of her missed
appointment, I asked for and was granted permission to clean her entire mandibular arch during
her next visit. Had patient pre-rinse with zero alcohol Listerine. Patient education session #1 -
Plaque and brushing. I defined plaque and the bass brushing technique, as using a 45-degree
angle of the toothbrush head towards the gingival tissue in order to removed the sticky white
film. Short term goal is to reduce plaque score by 0.3 each visit with a long term goal of reducing
the plaque score to zero. I also suggested incorporating the use of a childs toothbrush to reach
the distal molars. LL: Involvement Plaque score - 0.6, bleeding score - 2.7% Gingival description
- rolled margins maxillary lingual with slight BOP. Used benzocaine 20% topical on UR, then
periodontal charted and scaled they quadrant. Took intraoral radiographs to show recession.

11/9/17
Reviewed and updated A1C - down to 7.4 Blood glucose 119 mg/dl. Had patient pre-rinse with
zero alcohol Listerine. Patient education session #2: Periodontitis and flossing. Defined
periodontitis as the progression of gingivitis that is non-reversible, but the progression can be
halted. It involves a los of supporting tissues, recession and bone loss. I described flossing as the
mechanical removal of debris located between teeth with the proper technique being: use an 18
inch piece of floss, wrapped around the middle or ring finger, then use the thumb and index
finger to guide the floor between teeth, using a C shape to maximize surface area. Cindy
already has a habit of loosing 2-3 times a day, however I made sure to stress using the correct
technique to minimize damage to her gingival papilla. LL: Involvement Plaque score 0.5 - good.
Bleeding score - 2.7% Used 0.2ml Cetacaine on mandibular right and benzocaine 20% on
mandibular left. Ultrasonic and fine scaled mandibular arch.

11/15/17
Reviewed m/d history, blood glucose 129 mg/dl. Had patient pre-rinse with zero alcohol
Listerine. Plaque score - 0.3 - good, bleeding score 1.38%. Patient education session #3:
Explained how caries develop as a result of the acid bi-product of plaque causing damage to the
enamel surface. Told her how fluoride will act to restore the minerals in her teeth and reduce
sensitivity. Since I pre-viewed her third patient education at her last appointment she had already
called her dental office to find out they have reopened since hurricane Harvey. Her next short
term goal is to call and make an appointment. Her long term goal is to have the carious lesion on
the occlusal surface of #18 filled by the time I see her for her recall appointment in the spring. I
discussed having a prophylactic appointment every 4 months to haul the progression of her
periodontitis. LL: Involvement. Used 0.2mL Cetacaine on maxillary left, then scaled. Plaque
free. NaF 2% gel treatment; instructed her to wait 30 minutes before eating and drinking.

11/30/17
Reviewed m/c history, blood glucose 127 mg/dl. Had patient rinse with zero alcohol Listerine.
Gingival index =0. Plaque score 0.16 good, bleeding score 0%. Patient education: Continue to
use same brushing technique, however be mindful of how much pressure is being used when
brushing. At time I have noticed she is using heavy pressure while brushing, encourage her to
use light to moderate pressure while brushing to avoid increasing gingival recession. LL:
Involvement. Post calculus assessment. Post periodontal charting with Benzocaine 20% on all
four quadrants. Referral: DDS O. #18 for SA. Recall 4 months: 03/2018.

9. Prognosis
Overall I believe Cindy has a good prognosis. She already has a good flossing habit, which I
believe will keep her periodontal disease from progressing. I did evaluate her brushing method
and came to the realization she was using a lot of pressure. I advised her that she didnt need to
press so hard and that using gentler pressure would help preserve her gingival tissue and
decrease the likelihood of causing further recession. She is already missing a four teeth in
addition to her third molars, which prevents her from having a great prognosis. Her goal is to
hault the progression of her periodontitis, in an effort to keep the rest of her remaining teeth. We
did not discuss the option of implants, but that is a subject I plan on brining up during the spring
semester when I see her for her recall appointment.

10. Supportive therapy

Use of childs toothbrush to reach the distal molar surfaces. Demonstrated and recommended
using the bass brushing technique, a 45 degree angle and light to moderate pressure. Encouraged
her to continue her twice daily flossing habit, being mindful that she is using the appropriate
technique, a C shape to maximize surface areas and prevent damage to her interdental papillae.
Referral to DDS for a suspicious area on the occlusal surface of # 18. Recall: 4 months, March
2018.
11. Assessment of changes:
In the areas where there was an increase in pocket depths there must have been calculus
inhibiting me from reaching the bottom of the pocket with the periodontal probe. In areas where
there was a decrease in pocket depths there was gingival healing. Overall the color of her
gingival is now a light pink, whereas it was a bright fluorescent pink at the beginning of
treatment. This is most evident on her intraoral pictures. Working as a team with Cindy, where I
removed subgingival deposits and she maintained her at home oral hygiene, we were able to
improve her overall gingival and periodontal health.

12. Patient Attitudes and Cooperation

Cindy was very positive throughout the semester. It is a huge commitment to ask someone to
come for several appointments, especially when they are having to ask off or go into work late.
She was a very willing participant in the whole process. Even though she already has a well
developed flossing habit, she was very receptive to my patient education and listened closely as I
explained appropriate technique. She even asked very thoughtful questions that reveled that she
was highly interested in maintaining her oral health. Cindy was nice enough to make the
comment that I would be an asset for any dentist.

13. Personal Evaluations and reaction to experience

One of the major things I believe I could have done differently or better was my initial gingival
index evaluation. I believe that I may not have evaluated her with enough scrutiny. With the
experience that I have now, I think he initial number may have been slightly higher. However,
she also suffers from immune mediated diseases that can affect her capillaries, so I am willing to
theorize this may be why she never had a high bleeding score. I also think I could have kept
more detailed notes. I referred to my progress notes for journal notes and jotted down a very
generalized statement regarding her gingival statement at each appointment. Overall I enjoyed
caring for a patient in such a detailed manor. She has a lot going on systemically and as a result
is on a lot of prescription medications. This cause me to have to take a lot into consideration. I
think this experience also helped me organize my treatment thought process so I can bring the
best and most important patient education to the table with each patient that I treat.