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Patient Specific Dental Hygiene Care Plan

Patient Name: Age: 21 Gender: Male

Student Name: Amanda Stout Date: 3/21/18

Chief Complaint: Screening, cleaning, x-rays

Prophy Class: III Perio Class: II

Assessment Findings

Medical History At Risk For

19. Last physical in Oct 2017 ----------------------------------- Medical problems unaware of


27. Surgeries include: tonsillectomy June 2007------------------ Possible future complications from surgical procedures, pt
currently has no complications.
42. Pt experiences seasonal sinus problems -------------------- Obstructed airway if in supine position for extended periods

Social and Dental History At Risk For

85. Pt. drinks alcoholic beverages (1x a week)------------------- Hepatic damage, increase risk of systemic disease, cardiovascular
disease, digestive complications, stained teeth
88. Last dental visit was 2012 w BWX (cleaning) -------------- Caries, gingivitis, periodontitis, and oral cancer
92. Pt. gums bleed when brushing/flossing------------------ Increased risk of periodontitis, caries and opportunistic infections
93. Pt. teeth feel sensitive to cold and pressure--------------- Demineralization, possible incipient lesions
94. Pt. Clenches teeth when upset --------------------------- TMJ issues, attrition, abfraction, needs night guard
99. Pt. consumes sugary beverages less than 2x a week--- Demineralization, incipient lesions, cavities
Dental Examination At Risk For

pyknic body type ------------------------------------------------------- Increased risk of systemic diseases, high blood pressure,
cardiovascular diseases, and diabetes.
Prognathic ------------------------------------------------------------- Misalignment of occlusion could cause added stress to the
alveolar bone ultimately resulting in TMJ issues as time
progresses
Generalized ephelids etiology: developmental ----------------- Skin Cancer
Generalized scattered pustules on pt. face. Etiology: Bacteria-> Opportunistic Infection, scarring, possible Cancer
Single macule, normal color, normal border less than 1mm on
pt rt. Earlobe etiology: developmental----------------------------- Skin Cancer

Myopia etiology: developmental ----------------------------------- Condition can worsen/cancer

TMJ: slight deviation to pt. left slight clicking eti: stress,


clenching, malocclusion---------------------------------------------> Muscle tension/pain

Generalized scalloped surface texture--------------------------- Gingivitis or Periodontitis


Generalized red in max/mandibular anterior lingual-------- Gingivitis
Generalized edematous/spongy consistency--------------------- Gingivitis or Periodontitis
Generalized bulbous Shaped, papillae--------------------------- Gingivitis or Periodontitis
Generalized thickened margins---------------------------- Gingivitis or Periodontitis
Generalized 4mm pockets-------------------------------------- Periodontitis
Generalized mild bleeding throughout entire mouth --------- Infection, Periodontitis

Widened PDL space #24MD,#25D,#28D --------------------- Possible shift of neighboring teeth, occluding teeth, extraction
Attrition on maxillary/mandibular anterior teeth --------------- Demineralization, pain due to exposed dentin
Carious lesions #31DF---------------------------------------------- Root canal, loss of tooth

Dental charting:1,16,17,32 missing. 2Sealant, 3Sealant FM


hypocalcification, 5 LM hypocalcification, 6-7 attrition, 8 MI
fracture, 9 M fracture, 10-11 attrition, 14 Sealant, 15 DOF SA,
18 Sealant DLO SA, 19 Sealant, 22 attrition, 23 DI fracture, 24-
27 attrition, 28 DOL SA, 29 ML SA, 30 MF SA, 31 MF SA ----------
-------------------------------------------------------------------------------- Recurrent decay, tooth fracture, tooth pain

Periodontal Case Type: 2 Plaque Score: = 3.3% Bleeding Score: 9.5% (poor)

Gingival Inflammation: Generalized - Marginal


Biofilm: moderate Generalized
Biofilm Retentive Features/Predisposing Factors: Calculus, Malpositioned teeth, caries, nutrition, defective contact, mouth
breathing, tobacco use

Dental Hygiene Diagnosis

Problem Related to Risk Factors or Etiology


(1) Periodontal Case 2 (1) Plaque buildup, calculus, poor brushing/flossing habits, diet,
high bacteria count, moderate recession #14L, #24L, #25L

(2) Poor home care habits, uneducated about what causes


(2)Plaque
plaque buildup and how it harms the oral cavity and how to
properly remove plaque buildup.

(3) Carious Lesions (3) Xerostomia/etiology: bacteria- poor oral hygiene, infrequent
dental visits/Risk for progression of bone
disease/edentulous/root caries

Planned Interventions

Clinical Education Oral Hygiene Instruction


Scaling – hard deposit 1. Plaque 1. Define plaque and use flipbook page to
removal  What is it (sticky white deposits of demonstrate and explain how plaque can cause
bacteria) problems within their oral cavity. Discuss plaque
Polishing – soft deposit  What it looks like (sticky, clear film, food scores and educate pt. on bass brushing method.
removal debri) Have pt. demonstrate what they’ve learned, that one
 How to remove it (brushing/flossing) should begin Flossing, brushing mechanically 2X a day
Fluoride application  What it causes (if left to harden it to remove plaque; Can lead to gingivitis and
becomes calculus. If not cleaned then periodontitis if not done so.
the gums will get irritated which leads to
gingivitis)

2. Periodontitis 2. Explain to pt that periodontitis is the inflammation


 What is it--- irreversible/ clinical of gums, in combination with a clinical loss of
attachment loss attachment. The first stage of this is gingivitis, which
 How to manage and slow the is also called gum disease. Periodontitis is caused by
progression (brushing/flossing) plaque and calculus/tartar.
 How it can progress to a higher class of Periodontitis is NOT reversible. If not treated, it
periodontitis if no action is taken. progresses to a more severe form of Periodontitis.
Failure to slow the progression can cause an increase
in infection as well as loss of teeth and additional
bone. Use x-rays to show bone loss and use flip book
to show progression of disease. Teach patient how to
properly floss using the typodont as well as flipbook.
Have pt. demonstrate what they learned on their
own mouth. Make changes needed
3. Carious Lesion
-What it is (Cavity, hole in tooth) Start session by reviewing brushing and flossing
techniques learned from previous sessions. Ask Pt
-What it looks like how they are doing with new techniques. Watch
them demonstrate learned methods and revise if
-How it is caused (when pH of mouth is necessary. Explain to pt. that a cavity is a hole in the
between 4.4-5.5 over a long period of time) tooth caused by acid in the diet that is easily formed
if they do not stay diligent in these newly learned
-What it causes (demineralization of enamel, brushing/flossing techniques. Explain to the patient
can possibly remineralize) that they ultimately need to lower the pH in their diet
(reducing snacks and increase brushing/flossing)
advise pt. of the benefits of increasing fluoride as a
preventative measure and treating cavities before it
continues to progress.

Expected Outcomes

Goals Evaluation Method Time Frame


By 3rd
LTG 1: Reduce plaque score to 0.1 or less 1. Take a new plaque score @ each
appointment/end
appointment
STG: Define Plaque of treatment
STG: Discuss the importance of brushing 2X daily for 2 min
and flossing
STG: Correct patients brushing technique (teach bass 2. New bleeding score/physically look at the
method) gingiva (should see visible reduction in tissue By 3rd
LTG 2: Pt. will stop progression of periodontal disease by inflammation and color) @ each appointment appointment/end
reducing bleeding score from 9.5% to 7% also check pocket depths and bleeding scores of treatment
to compare prior results from previous
STG: Pt. will be able to define periodontitis as well as
appointments.
understand the symptoms of the disease.
STG: Teach the importance of flossing and correct
technique
STG: Pt. will learn about periodontitis on his own x-rays Restore cavity by
and learn the risk factors associated with periodontitis. next 6 months
3. X-rays, Annual oral exam, & dental charting
LTG 3: Get the cavity restored/filled (#31)
STG: Pt. will be able to Define Caries
STG: increase the patients knowledge on acid effects, diet
and ph levels.
STG: Increase the patients knowledge of fluoride
treatment
-find DDS

Prognosis Explain your prognosis


Good
Fair Patient states that he will improve his brushing and flossing method to at least 2x daily; As well
Poor as getting his cavity filled as soon as possible to prevent further decay. Also patient shows
Questionable interest in limiting his consumption of fermentable carbohydrates as well as late night snacking
Hopeless in order to help prevent his mouth atmosphere from reaching that critical pH level.
Furthermore, patient shows motivation to improve overall oral health.
Appointment Plan

Appt # Plan for Treatment Plan for Education, Counseling or Oral Hygiene Instruction

1 Medical/Dental Hx Define Plaque


Pre-Rinse X Teach proper techniques of brushing
Plaque/bleeding score Watch patient brush
Patient Education – Scaled UR Adjust/reeducate brushing if needed

2 Medical/Dental Hx Define Periodontitis


X
Pre-Rinse State how the patient can take steps to halt the progression
Plaque score of disease. Teach patient how to floss. Adjust/reeducate
Patient Education – Scaled UL flossing

3 Medical/Dental Hx Define Caries


Pre-Rinse Teach patient about diet, pH levels, acid attacks (4.4-5.5 over
Plaque score X a period of time)
Patient Education – Scaled LR Find DDS, discuss payments, scheduling appointment

4 Medical/Dental Hx
Pre-Rinse Evaluate progress, make suggestions, and adjust/reeducate
Plaque/bleeding score X
Patient Education – Scaled LL

Referrals: DDS for caries (#31)


Recall Interval: 6 month recall visits