Patient Specific Dental Hygiene Care Plan

Patient Name

Age

Student Name Christen Kennon

Gender:

M F

Date 04/18/16

Chief Complaint: Cleaning

Assessment Findings
Medical History
#83 Tobacco products (cigarettes- menthol) for 7
years: 10X a day; has tried to quit
once-------------------------------------------------------------------

At Risk For
Cardiovascular diseases, pulmonary diseases,
cancer, increased rate and severity of
periodontal disease, increased bone loss, loss
of attachment, and pocket depths, increased
tooth loss, shortened life expectancy.
Increased risk for caries, xerostomia.

#85 Alcoholic beverages: once every 6

months-----------------------------

Social and Dental History

#88 Last dental visit in 06/2015 for tooth
extraction--------------
#99 Drinks sugar containing beverages 3X a
day--------------------
#100 Chews gum (all
kinds)-----------------------------------------------

At Risk For
Gingivitis, periodontitis, dental biofilm (heavy),
materia alba, debris accumulation, caries.
Demineralization of tooth surfaces, increased
risk for caries

Dental Examination
Calloused hands: eti- weight
lifting--------------------------------------
Bilateral Lymphadenopathy: eti- seasonal
allergies----------------
Jaw deviates from right to left: etidevelopmental----------------
Lymphoid aggregates: etiidiopathic-----------------------------------
Plaque coated tongue- dorsal surface: eti- lack
of brushing,
smoking------------------------------------------------------------------------
Prominent lingual veins- ventral surface: etidevelopmental---
Generalized clefts
gingiva-------------------------------------------------
Generalized red
gingiva----------------------------------------------------
Generalized edematous/ spongy
gingiva-----------------------------
Generalized stippled surface texture:
attached---------------------
Generalized bulbous
papillae---------------------------------------------
Generalized rolled
margins-----------------------------------------------
Generalized 2 & 3mm recession in

At Risk For
None
Sinus drainage, recurring infection, sore throat,
headaches, halitosis, pressure caused by nasal
congestion
Limited movement of the jaw
None
Halitosis, altered taste
None
None
None
None
None
None
None
Gingivitis, periodontitis, root caries
Gingivitis, periodontitis, caries
Gingivitis, periodontitis, caries
Periodontitis
Tooth mobility, tooth loss
Periodontits, tooth loss
Root abscess, tooth extraction, root canal
therapy, infection of the pulp

posterior/anterior regions-
Localized 4mm pockets: #1, #16, #17, &
#32-------------------------
Generalized slight bleeding in posterior/
anterior regions-------
Mild horizontal bone loss:
UR/UL---------------------------------------
Widened PDL space: #24M and # 25
M&D----------------------------
Loss of crestal lamina dura: #3D and
#12D---------------------------
Caries on
#17D---------------------------------------------------------------

Periodontal Case Type:

Gingival Inflammation:

Plaque Score: 2.3

Bleeding Score: .03

Generalized, diffuse

Biofilm: Slight, generalized

Biofilm Retentive Features/Predisposing Factors: Calculus, malpositioned teeth, nutrition,
tobacco use
Dental Hygiene Diagnosis
Problem
1. Plaque----------------------------------------------------------------

Related to Risk Factors or Etiology

Poor oral hygiene, bacteria- major role in the
initiation and progression of dental caries and
periodontal infections, calculus formation, root
caries, root resorption, unpleasant esthetic
appearance, halitosis

2. Periodontitis--------------------------------------------------------

3. Caries-----------------------------------------------------------------

Induced by biofilm (dental plaque), poor oral

hygiene- gingival inflammation, bleeding gums,
periodontal pockets, loss of tooth- supporting
structures and alveolar bone, tooth mobility,
tooth loss

Poor
oral
hygiene,
bacteria,
frequent
consumption
of
carbohydratesdemineralization of tooth structures, infection,
pain, progression of periodontal disease, tooth
loss

Planned Interventions
Clinical

Education
Plaque

Oral Hygiene Instruction

Plaque is a white sticky film full of

Scaling hard
deposit
removal

Define
What it looks like
How to remove it
What it causes

Polishing soft
deposit removal
Fluoride application

Periodontitis
Define- irreversible
How to halt the progression of
the disease
Recall appointments

Caries
Define
Needs to include Fluoride (tap
water)
Demineralization/remineralizat
ion

harmful bacteria that develops on

the teeth. Plaque can be removed
with frequent brushing and flossing.
If left undisturbed it can lead to
gingivitis, periodontal infections,
dental caries, unpleasant esthetic
appearance, calculus (mineralized
plaque), and halitosis.
Periodontitis is the advanced stage
of gingivitis (gingival inflammation
caused by plaque) with bone loss
and recession. Periodontitis cannot
be reversed but the progression of
the disease can be halted by the
removal of dental plaque with
proper brushing and flossing. Taking
other preventive measures also help
to control the disease. Patients with
periodontitis should have routine
dental visits (every 3- 4 months).
Dental caries is a hole (lesion) in
the tooth caused by softening
(demineralization) of the hard tooth
structures (enamel, dentin,
cementum). Demineralization is
caused by bacteria and an acidic
diet.

Expected Outcomes
Goals

Evaluation Method

LTG 1: Reduce plaque score by .5 each visit.

The goal is a score of 1 or less by the last
visit.

1. Take a new plaque score at each

appointment and have the patient
demonstrate what you have taught
them.

STG: Define Plaque

Time
Frame
By the
last (3rd)
appt.

STG: Educate patient on brushing 2X a day

STG: Correct patients brushing technique
(teach the bass method)
LTG 2: Halt the progression of periodontitis
within 6 12 months.
STG: Define Periodontitis
STG: Teach the patient how to floss
STG: Reduce the patients bleeding score
by 1.0 each appointment.

2. Take a new bleeding score and

visually assess the color of the
gingiva and reduction in tissue
inflammation. Check pocket depths
and tissue heights at each
appointment. Recall appointments
every 3- 4 months.

6 - 12
months

LTG 3: Patient will have caries restored

STG: Define cavities
STG: Discuss how carbs and acidic drinks
change the pH of the saliva
STG: Discuss fluoride treatment and refer
patient to a dentist

3. Complete treatment and have

filling done by mid July.

By the
end of 3
months.

Prognosis
Good
Fair
Poor
Questionable
Hopeless

Explain your prognosis

The patient will succeed by taking necessary measures to improve

overall oral health such as proper brushing and flossing and frequent
dental exams. The patient has struggled to stop smoking cigarettes
and drinking less sugar containing drinks in the past but shows
willingness to work as a team toward trying to reach these goals
again.

Appointment Plan
Appt
#
1

Plan for Treatment

Medical/ dental history

Plaque/bleeding score
Patient Education
Scaled UR
Update medical/ dental history
Plaque/bleeding score
Patient education
Scaled UL

Plan for Education, Counseling or Oral

Hygiene Instruction
Plaque
Brushing and flossing

Periodontitis
Brushing and flossing

Update medical/ dental history

Plaque/bleeding score
Patient education
Scaled LR

Caries
Diet counseling

Update medical/ dental history

Plaque/bleeding score
Patient education
Scaled LL

Review plaque, brushing and flossing,

periodontitis, caries, and diet counseling.
Ask patient if they have any questions.
Go over anything that the patient does not

Complete full mouth scaling

Note plaque and bleeding score and goal
reached.
Complete treatment with polishing
(plaque free), and fluoride treatment.
Referrals: Decay on the distal of #17
Recall Interval: Every 3-4 months

understand.