Amanda Stout

Periodontal Care Plan Part 3

February 21, 2019

PERIODONTAL MAINTENANCE CARE PLAN

Patient Name: FEMALE. Age: 39

Date of initial Exam: 9/14/2018
Date of patient completed last semester: 11/9/2018
Date of periodontal maintenance visit: 2/22/2019

1. Medical History Updates: (include systemic conditions altering treatment, pre-

medication, medical clearance) explain steps to be taken to minimize or avoid occurrence,
effect on periodontal diagnosis and/or care. Compare to last semester and note any changes
or updates.

The patient’s medical history does not indicate any potential medical problems that may
complicate her follow up treatment. Overall, her health is good. All her vitals (pulse,
respirations, and temp.) are within normal limits. She still does not receive annual physicals to
check up on her health, her last physical to date still has not changed, which could still be an
issue for early detection of any diseases that could potentially occur. The patient has had no
recent surgeries other than the ones listed previously and the patient still shows no signs of
having been diagnosed with any systemic disease. The patient is currently still not taking any
medications, either OTC nor prescribed. This is why I classified my patient as ASA I. She also
has no allergen sensitivities and has not used any substances such as tobacco or recreational
drugs. The patient still consumes alcohol in moderation, and once again although no alcohol
would be ideal it is not detrimental to her oral cavity that she consumes these beverages on
occasion. The patient and her lack of using nicotine or tobacco products is a positive thing
because both tobacco and alcohol are high risk factors for periodontitis, oral cancer, xerostomia,
leukoplakia and carious lesions.

Overall the patient is still a good candidate medically and is less likely to have complications
from this follow up treatment plan. The patient shows enthusiasm to see how her pocket depths
have changed as well as her plaque and bleeding scores, as they reflect her recent brushing and
flossing habits since her previous appointment. The patient mentioned that although she has been
flossing more frequently, she has not made brushing 2x a day a priority which was very
disheartening for me to hear, because I want her treatment outcome to be successful and assist
her in aiding her periodontal condition and halting her disease. Patient willingness is key, and
she seems to show a renewed motivation to try to make it a priority again.
2. Dental History Updates: (past dental disease, response to treatment, attitudes, dental
I.Q., chief complaint, present oral hygiene habits, effect on periodontal diagnosis and/or
care)

The Patient’s chief complaint is for recall maintenance and a cleaning. The patient remembered
from last semester that her recall date was less than 6 months and that keeping up with her oral
hygiene is key to the success of a positive outcome when it comes to her periodontal health. I
informed my patient that due to the span of time that had passed, I wanted to take her to do some
one on one patient education and refresh her knowledge on oral health habits and things that she
could incorporate on the go and into her busy schedule. My patient is a college professor so
during the school semester, dependent on her workload her oral hygiene tends to be an
afterthought and not something on the forefront of her mind. This can affect the outcome of her
treatment due to unwillingness to handle her home care regime. She tends to build calculus and
plaque at a rapid pace, so home maintenance is a huge key in determining her success. The
patient had an FMX taken September 14th 2018 with vertical bitewings to check the bone loss
and carious lesions. I updated her radiographs due to a suspicious cyst on her gingival area near
tooth #3. The radiographs taken were periapical, a molar and a canine shot to check the apices, a
periapical pathology was noted on the apices of tooth #3. The patient has had numerous
restorations and a few root canal therapies. The tooth in question has a defective restoration and
is showing signs of recurrent decay as well as possible recurrent decay on the mesial of tooth #5.
The same suspicious areas were present from her previous appointment as well as the broken
crown on tooth #19 which had still not been repaired. I questioned the patient about her
reasoning as to why she has not handled these referrals from her previous appointment and her
response was she lacked the time and was unsure as to what dentist in the area would be the best
fit for delivering her treatment. In our previous appointment I had printed out a list of dentists in
the area around where she lived that specialized in the particular treatment that she needed, and
during our current appointment today I offered to reprint her out a copy in case she had
misplaced hers. The patient stated that she did have her copy still and would look into getting the
work done. I suggested that since she teaches, spring break would be an ideal time to set a goal
to get her referrals taken care of. The patient agreed. The patient still consumes diet cokes
constantly throughout the day as well as snacks on mini M&Ms which in turn aids in the
demineralization and erosion of her enamel. This can lead to the breakdown of the enamel and
can cause carious lesions and recurrent decay. Based on the following findings, I believe her
periodontal status has the potential to progress and lead to more loss of bone. This is why I
emphasized to her that although we are a team and are in this together, that it is vitally important
that she does her oral hygiene work as well. She has to make better habits and prioritize her oral
health before she stands any chance of halting her disease progression.
3. Oral and Dental Examination Updates: (lesions noted, facial form, habits and awareness,
consultation) and (caries, attrition, midline position, mal-relation of groups of teeth,
occlusion, abfractions) Compare to last semester and note any changes or updates.
The Extra/Intraoral Exam remained the same.

No pathologic finding from this exam, the only atypical findings was the intraoral exam near
tooth #3 while using the ultrasonic and retracting her lip I noticed an area that resembled a cyst.
Less than 2mm in diameter. I questioned the patient and she has had this since her previous
appointments and that it usually goes away on its on and comes back. The patient believed she
ate something hot and burned her gingiva. Upon further investigation, and with a consultation
from both the dentist on site and my instructor we decided to take radiographs to check the area
to see what type of pathology this area was. Radiographs determine this was a periapical
pathology on tooth #3. This can affect the state and health of her periodontium if she does not get
this problem looked at and restore her restoration on tooth #3. The infection can potentially leak
into the bone and cause more bone loss over time. This would not benefit the patient nor her
periodontal status.

Posture/gait: normal
Physical limitations: none
Skin/nails: normal
Eyes:normal
Lips: normal
TMJ: normal, with slight deviation to patients left, no popping sounds or pain
Tonsils: normal

Soft palate, uvula, hard palate, and labial mucosa: normal

Buccal mucosa: bi lateral linea alba, due to grinding and clenching
Vestibule: normal
Salivary flow: normal
Tongue/border of tongue: normal
Tongue thrust: slight when patient swallows

Oral habits: patient is still grinding while sleeping and clenching when stressed or
concentrating, patient still does not have a night guard.

Clenching overtime can lead to attrition and breakdown of enamel. It can cause tremendous
amount of pressure on the teeth as well as the gingiva and alveolar bone. With continuous force,
this can lead to exposed dentin making the patients teeth more sensitive and prone to caries,
gingival tissues recede exposing root surfaces, damage to the periodontium and even TMJ
problems. These factors can affect the progression of her disease.

Occlusal examination:
Right side: molar—unclassifiable Left side: molar---unclassifiable
Canine: class 1 Canine: class 1
Overbite is 3mm and overjet is 1mm, midline shift is 1mm to the right.

Other: she also still has crowding on her upper anterior teeth, her central incisors on both the
mandible and maxillary show extreme crowding and lingoverted, which can be a significant
contribution to plaque accumulation. The patients tooth location makes it difficult to brush those
hard to reach areas where bacteria can harbor aiding in the progression rate of her current
periodontal disease.

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

Case classification: IV Periodontal Case Type: II

Gingival description: Patient had generalized scalloped architecture, generalized red with
localized magenta between the facial of 24&25 and 23&22 as well as the lingual anterior teeth.
This was the same as her previous appointment which indicated what she is collecting plaque
and biofilm within the same areas, especially in those lower anteriors due to crowding.
Consistency: edematous and spongy generalized. Margins: generalized roll with the exception of
the lingual anteriors and facial anteriors of both the maxillary and mandibular, they were
thickened. Papillae generalized bulbous, Surface texture (papillary and marginal) generalized
smooth, surface texture(attached) generalized stippled. No suppuration found.

Comparison of periodontal condition: The patients periodontal condition stayed the same
from her previous appointments which shows that she is still harboring plaque and bacteria and
with the inflammation and then bleeding in certain areas that indicated an active infection.
Generalized gingival inflammation and affects of the marginal and papillary gingival tissues. The
patients periodontal assessment shows that infection is occurring within the tissues and plaque
accumulation is causing the tissue to migrate apically. To prevent progression of the diseased
state the patient should begin practicing prompt oral hygiene methods such as brushing at least
2x a day and use floss daily with alcohol free mouth rinses to reduce the accumulation of plaque
and biofilm in the oral cavity. I have reiterated to the patient that our goal is to assist her in
HALTING the progression of her disease and to help instill those good oral habits that she can
incorporate into her hygiene routine. The goal is to assist the patient in making these practices a
habit, so she can help fight her battle of periodontal disease.

c. Plaque Index: App’t 1: 2.5% Fair

This went up since the patients last appointment, she mentioned she does not brush as often as
she should due to her demand at work. I emphasized how important brushing is to her oral health
because plaque can ONLY be removed by mechanical forces, aka brushing. I explained that
plaque and her specific host response is what is exacerbating her disease process and causing her
periodontal state to decline.
e. Bleeding Index: App’t 1: 2.4% Fair
Although her bleeding score went down from her last appointment I noticed when doing her
gingival assessment a lot of redness and inflammation. Also during her cleaning I noticed an
extreme amount of bleeding during calculus removal. The patient states that she has been
flossing everyday, and when I questioned her on the technique I was very proud when she
correctly acknowledge the proper way to floss using the “c” shape as well as alternating the
string so as not to spread bacteria to other parts of her mouth. Bleeding is a sign of infection so
any indication of this is not a good prognosis for her periodontal health. Bleeding indicates
something is happening below the surface and her body is responding to it. This could lead to
further bone loss and disease.

g. Periodontal Chart: (Periodontal Maintenance probe depth and recession data)

My patient still has a few 4-5mm pocket depths, especially on her lower mandibular premolars
on the lingual aspect as well as her premolars in her mandibular region. This indicated that
periodontal disease is still present, the deeper the pocket the more at risk for pathogens and
bacteria to get deep down within that area and wreak havoc on the patients periodontium. The
deeper the pocket, the harder to clean and the more at risk the patient becomes for chronic bone
loss if not taken care of and handled properly. A few of her pockets decreased dramatically, for
example, #15M decreased from a 7mm pocket to a 4mm. This is still considered high, but it is a
vast improvement from her previous appointment. The patient still shows recession on the facial
of tooth #14- 2mm, 1mm on the facial and lingual aspect of teeth #24, 25, 26, 22.

5. Treatment Plan: (Include assessment of patient needs and patient education plan)

The patient is lacking in certain home care regimes and not making her oral health a priority.
Although she has bought herself a powered TB, she does not use it as indicated at least 2x a day.
The patient was classed as a prophy IV her last appointment and again this appointment almost 5
months later. This indicated to me, which I reiterated to her that she indeed builds up plaque and
calculus at an exponentially fast pace. This is why it is crucial that she adhere to her at home
regime of brushing at LEAST 2x a day. If she does not she will cause her periodontal disease to
progress and get worse over time. I want to be able to give my patient the tools and skills to help
assist her in halting her disease. I explained that the teeth we are born with, and accumulate over
life are what we have to last us until we die. They must be able to withstand the test of time or
she’ll be eating oatmeal through a straw due to her mouth potentially becoming edentulous if her
disease progresses to that point. I began the patient education session by reviewing and
recapping her long term and short term goals.

STGs and LTGs are located on the following page:

App't 1: Short/Long Term Goals:

LTG 1: Patient will bring plaque score to “good” by her last appointment.
STG: She will be able to define plaque by her next appointment.
STG: She will lower score by 0.5 each appointment.
STG: She will demonstrate proper brushing technique by her next appointment.
LTG 2: Patient will halt the progression of periodontitis disease by third appointment and try to
obtain no bleeding points by last visit.
STG: She will define Periodontitis by the next appointment.
STG: She will understand the importance of flossing daily by next appointment
STG: Patient will demonstrate proper flossing techniques “c” shape by next appointment
STG: Patient will lower her bleeding score at each appointment by 0.1.

LTG 3: Prevention of future caries at her recall appointment/ and handle all referrals for her
current areas of decay and to fix the crown on tooth #19 by next appointment
STG: Patient will define the caries process by her next appointment.
STG: Patient will discuss carbs/acidic diet and the pH level by next appointment
STG: Patient will use fluoride rinse daily to help prevent future caries.

I went over these goals by quizzing my patient and inquiring does she remember what plaque is?
Does she remember what plaque causes if left on the tooth surface? How do you remove plaque?
At first the patient was hesitant to answer but as the session continued she grew more confident
and comfortable and I could tell that she had retained the bulk of the information from our
previous sessions. She explained to me that plaque is bacteria that forms in the mouth, that it can
adhere to the tooth surface and cause demineralization. That by eating sugars and fermentable
carbohydrates that this mixed with the bacteria in the plaque can release acids that affect the pH
in the mouth. I explained to her what happens when the pH is affected, that it can begin to seep
away the minerals from the enamel of her teeth, and that by doing so makes the tooth structure
weak and susceptible to decay. I had the patient demonstrate a manual brushing technique, that
although she now uses a powered TB she on occasion uses a manual TB when on vacation. I
quizzed the patient on the proper flossing technique and what shape we used floss in order to be
the most effective in getting the bacteria out from the interproximal of the teeth. I explained that
flossing helps to remove that bacteria, and if left undisturbed it can sink down into her pockets
and cause inflammation and bone loss. That brushing only removes 60% of the plaque and
biofilm and that by not flossing she is missing a substantial amount of bacteria. I showed the
patient her pocket depth charting from Eaglesoft and compared it to the measurements I took
prior to going into the patient education session. I congratulated her on her progress but also
pointed out areas that she needed to keep an eye on and watch. I handed her a copy of the
charting so she could take it home and know which teeth she needed to pay extra special
attention to. I explained to the patient that we are a TEAM. TEAMWORK is key. I also
reminded her that I can give her education and clean her teeth 2938292 times but if she is not
keeping up with her oral hygiene home care and doing her part, she will be fighting a losing
battle when it comes to the state of her periodontal health. I told her I am here for her and one of
her biggest cheerleaders when it comes to her success in halting this disease and that I have faith
she will do what she needs and begin making brushing a flossing habitual in her everyday life.

6. Prognosis: (Based on attitude, age, number of teeth, systemic health, malocclusion,

periodontal examination, maintenance availability)

The patient shows a very positive and upbeat attitude when it comes to her oral health. My goal
for her is to keep that motivation and excitement when she is at home having to incorporate these
habits into her busy schedule. The patient tends to put her oral healthcare on the backburner and
not fully put it as a priority. The patient continues to have several suspicious areas and
restorations that need to be repaired that she has yet to address. This makes me concerned due to
the fact that she showed the same upbeat motivation in our previous sessions about putting her
oral health first and getting those restorations handled, yet nothing has changed in that regard.
The patient has excuses that will ultimately stand in the way of her attaining a good prognosis on
the outcome of her treatment and halting her periodontal disease. On a positive note she has kept
up with her recall appointments and has been very determined to keep up the habit of flossing.
That is one habit that she has consistently adapted and stuck with over the course of her
treatment, so this in turn shows that she is capable of making changes in a positive way. If she
can incorporate brushing more frequently and handling her referrals I think there may be hope
for her to turn around her prognosis. As of now, If she maintains her current habits I do not see a
positive coorelation within her overall periodontal status and disease.

7. Supportive Therapy, patient attitude and cooperation: Suggestions to patient regarding

re-evaluation, referral, and recall schedule. Patient’s attitude and level of cooperation
towards periodontal maintenance therapy.

Patient has agreed to come back for her recall appointment in the May of 2019 to reassess her
gingival tissues and overall healing. The patient is aware that there is a risk of her periodontal
disease progressing if she does not maintain her home care as well as upkeep of her recall
appointments. I explained to her that although I will be graduating I can make sure she is added
to the patient list for another clinician, and that it is most beneficial for her overall periodontal
health that she adhere to her recall times. The patients attitude sees very optimistic and upbeat
and determined to both obtain and keep a healthy oral cavity. I set a goal for her to brush at least
2x a day, even if she is tired and exhausted from work to set a timer and alarm on her phone to
be sure she meets the requirements for that day. The patient understands that she needs to have
her dental restorations on tooth #3, and tooth #19 restored as well as have her periapical
pathology looked at on tooth #3. The patients understands she has suspicious areas on tooth #5M
and that by not addressing these issues it can exacerbate her periodontal disease.

8. Assessment of Changes: (including plaque control, bleeding tendency, gingival health,

probing depths, patient oral hygiene habits)

I have witnessed numerous changes in this patient just from the last time she was in the clinic.
Her pocket depths and bleeding score reduced, but despite this I did notice a substantial amount
of plaque accumulation on her lower anteriors. I deducted this reasoning to be due to the
crowding she experiences there as well as her lack of brushing. The patient is aware that her
brushing habits need to change in order for her oral cavity to transition to a state of health. The
patient also shows an active periapical infection that is causing issues with her oral health. This
is a prime reason why not addressing your oral needs and referrals in a timely manner can cause
more pain and issues to your periodontium and surrounding structures. The patient also had a lot
of inflammation, particularly around the facial and lingual anterior teeth. This is similar to her
previous appointments, and although it initially went down at her post cal evaluation, it has
progressed back up to a state of concern. Inflammation and bleeding show an active disease is
present, so it seems as though certain aspects of her oral health are progressing backward (
towards disease) rather than foreword to a state of health. This will be an issue in the long run as
well as for the concern of longevity of her teeth. The patient is aware that we cannot REVERSE
her periodontitis but we can take steps to HALT the progression of her disease. A new evaluation
will be conducted in May 2019.