Health Assessment/Medical Assessment

Health Assessment/Medical Assessment
A medical assessment of patient A revealed that her health overall was good with a normal blood pressure of 119/69mmHg, further affirmed by the fact that she was not taking any medication. The patient reported that she was not allergic to anything, with records showing that she was not pregnant on her last visit 6 months ago. Further, the patient reported no complications to the 4 horizontal bitewings ordered by the doctor at the last visit. However, the patient did report suffering from some recurrent headaches, as well as wearing contact lenses.
Dental Assessment
A probing depth of between 2s and 3s without force resulted in bleeding on probing. Recession was also observed on the following teeth: 3,5,12,13,14,18,19,20,21,29,and 31. The patient was missing third molars (1, 16, 17 and 32) with calculus found subgingivally on teeth 25 and 28. The assessment however, revealed no mobility, exudates, open contact, drifting, furcation or food impaction. Tooth charting findings confirmed the absence of all the third molars, occlusal composite on teeth 2, 13 and 31. There was DO composite on tooth number 29, MO composite on tooth 30, and OL and occlusal amalgam on teeth 14 and 15, 18, 19 respectively. The charting also revealed attrition on teeth 22, 27, 4, 11 and 6. There was no hypoplasia, decalcification or abrasion, although number 15 mesial and 29 distal need to be observed keenly in subsequent sessions.
Oral Exam
An oral examination revealed generalized macules, bilateral linea alba, rolled gingival between tooth 18 and tooth 20. There was also palatal tourus, and bilateral mandibular tori as well as tissue tag. Number 12 was lingualverded, with class 1 bilateral occlusion also observed. Everything else was found to be within normal limits.
Oral Hygiene
The patient recorded a plaque free score of 80.4, and reported brushing twice a day, grinding and clenching her teeth, as well as carrying out mouth rinses 3 times a day. Further, she also reported flossing every other day, not smoking, and using sensodine mainly due to tooth sensitivity. She admitted that her last dental visit was the one she had come for 6 months ago. The patient was advised to reduce the number of mouth rinses from three to two, as well as floss more; at least twice a day, rather than every other day. Although the patient does not smoke, she did confess to liking sugary foods, particularly candy.
Dental Hygiene Diagnosis
ASA Code: On the basis of the ASA code, the score was one, because the patient is in good health and doesn’t take any prescription medication. The patient is 32 years old, has a blood pressure that falls within the normal range, a normal pulse and is not allergic to anything.
AAP Code: AAP is one slight because the patient does not have any record or sign of bone loss. Although the patient has signs of recession, as well as bleeding on probing, which would make the diagnosis an AAP code 2, I made it one because I was advised to do so based on the fact that the overall oral condition of the patient was good. This is further affirmed by the fact that the patient does not have any mobility, furcations or exudates, characteristic of an AAP code 1.
Overall, the patient is in good condition and has no medical or dental concerns of note
Treatment Plan
The plan will be based on the patient’s medical history, the perio chart, the oral examination, hard tissue chart, plaque free score, and oral hygiene instructions. Someof the potential measures likely to be taken include: manual scaling, polishing, the use of a fluoride tray (Naf) and the continued use of four horizontal bitewings. Based on my assessment, the patient will only need one appointment. The plan concentrated on the patient’s need to floss twice daily, as evidenced by the plaque free score. In addition to showing the patient how to floss, I also recommended that the patient uses antimicrobial mouth rinse due to the bleeding observed following probing a finding that I felt could lead to serious problems in the future. The patient was also advised to ensure they at least brush their teeth, or rinse their mouth thirty minutes after eating sugary foods or taking sugary drinks. Due to the fact that the patient has restorations, some nutrition concerns, as well as bleeds upon probing, fluoride treatment specifically using Naf due to composites was recommended and explained to the patient
The treatment started with the 4HBTW and involved the use of the following instruments:
i) 204s for interpoximal areas
ii) Columbia 13/14 for posterior teeth
iii) ½ for anterior teeth
There were no difficulties experienced during the procedures, and the treatment plan was followed to the letter, with only one appointment required to complete it.
The patient was in good condition and displayed an understanding of the importance of oral hygiene. As such, I do believe that the patient will follow the recommended instructions. There was no need for a referral, as there were just a couple of teeth that needed to be watched (15 and 29). The next recommended visit for recare was set for 6 months, as the patient was in a position to take care of their oral health. Overall, I learned that patients are usually quite willing to take care of their health if given the right instructions. Treating this patient definitely made me a better hygienist because of the unique nature of the case. Experiencing different oral hygiene challenges and different situations will make me a better hygienist.
I learnt that my competencies are time management, the organization of patient files, as well as providing explanations on the importance of oral hygiene aids.