1.

Assessment

A. Patient interview: Chief complaint is that the patient has a broken tooth

and his mouth is very dry. He is retired and has not seen a dentist in over

10 years.

B. Medical/dental history: Patient has Parkinson’s disease, type II diabetes,

hypertension and early dementia. He is taking Lisinopril, Glucotrol,

Sinemet and Lexapro. He is allergic to Penicillin. His symptoms of

Parkinson’s are tremors in his hands, stiffness in his joints and impaired

balance. His dementia symptoms are mild and he is able to function. His

last A1C was 7.5. He also has been told that he is a mouth breather. His

blood pressure was 135.88, respirations were 100 bpm and respirations 18

breaths per minute. He has not been to the dentist in over 10 years. His

home care consists of brushing with a hard bristled toothbrush once a day,

no flossing and occasionally rinsing with hydrogen peroxide or saltwater.

He is not sure if his toothpaste contains fluoride and buys whatever is on

sale.

C. Identify implications to treatment of special needs patient: During the

appointment the patient may need frequent breaks because of the

Parkinson’s disease. He also may need assistance getting in and out of the

chair. Laying the patient all the way back may be difficult so standing

might be best. Adding 5-10 minutes to the appointment could also benefit

the patient and the clinician.

D. Social history: No known history of smoking or drinking.

E. Vital signs: Blood pressure: 135.88, Heart rate: 100 bpm and Respirations:

18 breaths per minute.

F. Intra/extra oral examination: Extra oral: WNL, no significant findings.

Intra oral: Tenderness in maxillary left quadrant with inflammation and

inflammatory infiltrate in the area of tooth #12. Maxillary anterior

attached gingiva is pink and stippled, but the marginal gingiva has redness

and swelling generalized throughout the mouth.

G. Periodontal examination: Bleeding index was a 65%. Plaque score was

35%. Generalized heavy BOP. Suppuration on #32 distal lingual.

Generalized 4-5mm pockets and localized 6 and 7mm pockets to the UR,

UL and LR quadrants. No furcations noted. Class II mobility on teeth #3,

10, 11 and 15. Class I mobility on #32. Generalized recession. 10+ teeth

missing.

H. Relate oral changes based on special needs patient: Generalized attrition

could be from extra movements referred to as dyskinesia from the

Parkinson’s disease. His Parkinson’s disease may also be attributing to his

high caries rate because Carbidopa can cause Xerostomia.

I. Patient also may have a difficult time with oral hygiene because of the

tremors in his hands making it difficult for him to brush and floss

properly. His dementia could also be contributing to poor oral hygiene.

J. Radiographs if available: Panorex available. #1, 2, 4, 5, 13, 14, 16, 17, 18,

19, 29, 30 and 31 are missing. #3 and #15 are tipped mesially and

supraerupted. Tooth #12 is fractured at the gum line. Radiopacities distal

 to tooth #6. Bone loss is evident but difficult to determine extent based off

Panorex, would need FMX.

2. DH Diagnosis

A. Level of health: Poor.

B. Diagnosis: Stage IV grade C periodontitis due to > 50 % bone loss,

secondary occlusal trauma, severe ridge defects, bite collapse, drifting,

flaring, masticatory dysfunction, < 20 teeth remaining, > 5mm CAL and

probing depths > 6mm. Grade C because the destruction exceeds biofilm

deposits and the A1C is > 7.0%. Patient may be experiencing more bone

loss due clenching and grinding from the Parkinson’s disease which can

result in secondary occlusal trauma that can cause damage to the

periodontium.

3. Plan

A. Consultations necessary: Needs a comprehensive exam first to diagnose

and plan for future visits.

B. Treatment goals: Stabilize periodontal disease, eliminate BOP, reduce

probing depths and attachment, reduce inflammation, reduce biofilm,

reduce size of gingiva and get back to a healthy normal color.

C. Addresses phases of treatment: 1) comprehensive exam 2) extraction of

#11 and 12 3) phase 1 SRP 4) phase 2 SRP 5) phase 3 SRP reevaluation.

4. Implementation

A. What will happen at the appointments: 1st appointment comprehensive

exam (discuss night guard, take FMX). Most likely address extractions of
 #11 and 12 first because of infection and deep decay. Recommend SRP all

4 quadrants. Periodontal therapy will need 3 appointments with local

anesthetic. Use Gracey curettes and cavitron for removal of calculus.

Phase 1) SRP UR and LR, phase 2) SRP UL and LL, phase 3) 4-8 week

reevaluation. Prescribe a chlorhexidine rinse, apply stannous fluoride, and

Arestin to control bacteria and biofilm buildup and review OHI. Discuss

electric toothbrush, soft bristled, waterpik or floss with holder, Prevident

dry mouth and Biotene rinse. Can also recommend OTC dry mouth aids

like lozenges. Also talk to patient about using a floss holder to help make

flossing easier since he has limited dexterity. He may also want to use a

toothbrush with a larger handle with grip for control.

5. Evaluation

A. How will you or how did you evaluate care: Changes in BOP, CAL,

biofilm, and inflammation. Assess for subgingival calculus and may need

to re-instrument and review OHI.

B. Follow up charting: Full mouth probe, BOP, CAL, biofilm.

C. Radiographs: CMS to check for any residual calculus.

D. Patient OH behavior changes: Check healing and soft tissue response to

instrumentation, changes in probing depth, use of tobacco or control of

systemic diseases, motivation for daily oral self care, mental health issues

and stress impacting self care. Check to see if patient is doing okay using

floss holders and larger toothbrush.

 References

Boyd, L.D., Mallonee, L.F., & Wyche, C.J. (2021). Wilkins’ clinical practice of the dental

hygienist. Jones & Bartlett Learning.

Clark, S. (2023). 103: Assessment and treatment planning [PowerPoint slides]. Talon.

https://talon.kirkwood.edu/d2l/le/content/179528/viewContent/4918056/View