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Patient Specific Dental Hygiene Care Plan

Patient Name _____Prentiss Hopson______ Age __61__ Gender: M F

Student Name _Rachel Hopson________ Date ___4-2-2016___

Chief Complaint:
Cleaning
Assessment Findings
Medical History At Risk For
#25 Baby Aspirin and Vitamin C #25 No risk
#27 Orthoscopic knee surgery to repair #27 No risk
tendons #83 Oral Cancer
#83 Chews Tobacco #92 Gingivitis/Periodontitis
#92 Bleeding when flossing #93 Increased Sensitivity ( as a result of
#93 Teeth are sensitive to cold recession)
#94 Clenches Jaws #94 Abrasion, Jaw pain/tenderness, TMJ,
#95 Grinds teeth Limited opening
#95 Abrasion, Jaw pain/tenderness, TMJ,
Limited opening
Social and Dental History At Risk For

1 Infrequent dental visits ( last visit: 6 1 gingivitis/periodontitis, plaque, caries


years ago, in 2010) 2 Recession and/or abrasion
2- medium tooth brush 3 Gingivitis & Periodontitis (if he didnt brush
3 Brushes twice a day as frequently)
4 Floss (rarely) 4 Gingivitis, Periodontitis, caries
5 Rinse ( not regularly ) 5 Gingivitis, Periodontitis, caries
6 Wisdom teeth removal 6 No risk
Dental Examination At Risk For

1 Dry cuticles 1 None


2 mesognathic profile 2 None
3 scattered ephelids 3 skin cancer
4 dry, chapped lips 4 bleeding
5 maxillary torus 5 continuous growth
6 mandibular left torus 6 continuous growth
7 popping sound originating in left jaw 7 inflammation, soreness, tenderness,
8 mandibular exostosis limited opening
9 Grinding ( at night) 8 continuous growth
10 Clenching (at night and when stressed) 9 Abrasion, chipping/fracturing of teeth, TMJ
11 mouth breathing 10 Abrasion, chipping/fracturing of teeth, TMJ
12 moderate generalized biofilm 11 xerostomia
13 heavy localized biofilm 12 bacteria, calculus
14 - Calculus 13 bacteria, calculus
15 Redness of tissue around mand. and 14 gingivitis/periodontitis, caries
max. molars 15 gingivitis/perio disease
16 Generalized Recession (moderate) 16 Sensitivity, root caries due to root
exposure

Periodontal Case Type: 3 Plaque Score: __1 - good___ Bleeding Score:


_0.1%____
Gingival Inflammation: None
Biofilm: moderate generalized, and heavy localized to #23-#27
Biofilm Retentive Features/Predisposing Factors:
Calculus, Malpositioned teeth, defective restorations, and periodontal pockets.

Dental Hygiene Diagnosis


Problem Related to Risk Factors or Etiology

1 Plaque 1 Results to calculus -> demineralization ->


caries
2 Periodontitis
2 Due to infrequent dental visits, bacteria,
3 Tobacco
incorrect brushing style, not flossing
4 Mouth breathing
3 Staining, oral cancer, halitosis,
periodontitis, bacteria
4 Xerostomia, higher risk for caries

Planned Interventions
Clinical Education Oral Hygiene Instruction
1 Plaque 1 Brushing at morning and at night
Scaling hard - Describe what it is (sticky Flossing daily
deposit deposits of bacteria)
removal - What does plaque look like
(sticky, clear film, food debris)
Polishing soft - How to remove it
deposit removal (brushing/flossing)
- What it causes (if left to
Fluoride application harden it becomes calculus. If
not cleaned then the gums will
get irritated which leads to
gingivitis/periodontitis)

2 Brushing at morning and at night


Flossing Daily
2 Periodontitis Regular Dental Visits
- Describe what it is
(inflammation on gums,
gingival tissue)
- What causes it (accumulation
of plaque/bacteria biofilm
releasing substances that
cause inflammatory reaction as
well as smoking)
- How to halt the progression
(brushing/flossing)
- It is not reversible, but can be
stopped from progressing.
3 Brushing at morning and night
Flossing Daily
Tobacco Cessation
3 Tobacco Use of a mouth rinse daily
- What it is (what Is in tobacco,
nicotine)
- Different forms of tobacco
(smokeless, cigarettes, vapors)
- What it causes ( oral cancer,
lung cancer, staining of teeth,
halitosis, tooth loss,
periodontitis)
- Ways to stop (Chew sugar free
gum with xylitol, let someone
know you are trying to quit so
that they can encourage you)

Expected Outcomes
Goals Evaluation Method Time
Frame
End of
LTG 1: Reduce plaque score below 0.1 1. Take a new plaque score at
Treatment
every visit
STG: Know what plaque is

STG: Know how to brush properly

STG: Know how to floss properly


End of
LTG 2: Halt Periodontitis treatment
2. Evaluate gums and take
STG: Know what periodontitis is
bleeding score at each
STG: Show how to floss correctly and appointment. Also take
effectively bitewing radiographs once
every six months to monitor
STG: Reduce bleeding score at each bone loss.
Since
appointment
patient
LTG 3: Reach tobacco cessation does not
use it all
STG: Be informed of the risks of tobacco
the time,
STG: limit tobacco use to no more than 1X 3. Patient education on we are
a week brushing, flossing, and going to
tobacco cessation. Remind aim for
STG: Limit tobacco use to less than 1 X a tobacco
patient of each topic at each
month cessation
appointment. Be genuinely
sincere and ask patient how by next
he is doing with trying to quit recall
tobacco at each appointment. appointm
Encourage patient and be a ent. (6
fan when he is doing well!!! months)

Prognosis Explain your prognosis


Good *** Patient shows interest in quitting and wants to get on a regular
Fair recall to have his teeth cleaned every six months.
Poor
Questionable
Hopeless

Appointment Plan
Appt Plan for Treatment Plan for Education, Counseling or Oral
# Hygiene Instruction
Define Plaque
1 MDX Help them to learn to brush correctly
Take plaque score Watch pt to see if they have improved
Brushing/plaque patient education Correct pt If they need more help
Pre Rinse Encourage patient!
Scale UL
MDX Define periodontitis
2 Take plaque score Help them to learn the correct way to brush and
Flossing/Periodontitis patient ed. floss
Pre rinse Watch pt to see if they have improved
Correct pt where it is needed
Scale LL
Encourage the pt!

Define tobacco cessation


3 MDX Inform pt of the risks associated with tobacco
Take Plaque score products
Patient education on tobacco cessation Go over proper brushing and flossing techniques
again
Pre rinse
Encourage pt to try chewing sugarless gum with
Scale UR
xylitol instead of getting tobacco.
Tell pt to let someone close to him know that
hes trying to quit so that they can provide
encouragement.

MDX Define plaque, periodontitis, and tobacco


4 Take plaque Score cessation.
Chair side patient education of all Give them a review of each topic.
the topics we had previously discussed Watch patient brush and floss
Correct them if needed.
Pre rinse
Encourage the patient & let them know that
Scale LR
TOGETHER, We, can reach these goals!
Plaque Free
Fluoride Treatment
Referrals: If patient is interested, we can refer to DDS to have missing teeth replaced.
Recall Interval: 6 months