Patient Specific Dental Hygiene Care Plan

Patient Name _________Dale Roberts_____________ Age ____62______ Gender: M F

Student Name _________Madison East_____________________ Date ___03/20/2018_______

Chief Complaint: Cleaning

Prophy Class____Class III___ Perio Class____Case II___

Assessment Findings
Medical History At Risk For
1) Pt is on Allopurinol for gout 1) Poor healing

2) Pt is on Dyazide 2) Upset stomach, xerostomia, nausea

3) Pt is on Ex Forge for high blood pressure 3) Monitor vitals, stress, anxiety

4) Pt is on Lipitor 4) GI side effects

5) Pt is on Prilosec 5) GI side effects, xerostomia

6) Pt is on tramadol for restless leg 6) Xerostomia, cross hypersensitivity risk to opiod

analgesics
7) Pt had surgery on big toe 20 years ago and doesn’t
remember which foot 7) None

8) Pt had 3 back surgeries most recent was 8 years ago 8) None, just watch patient position and keep them
comfortable
9) Pt had eye surgery 30 years ago. Radialectomy to
correct nearsightedness 9) None

10) Pt had Tonsillectomy 10) None

 11) Pt has high blood pressure and is on medication 11) Monitor vitals, stress. Anxiety

12) Pt is allergic to Keflex 12) Anaphylactic shock

Social and Dental History At Risk For

1) Pt last dental visit was 7 years ago before he retired 1) Caries, gingivitis, periodontitis, demineralization

2) Pt had FMX Feb. 21, 2018 2) None

3) Pt drinks diet coke one time a week 3) Caries, demineralization

Dental Examination At Risk For

1) Mesognathic 1) None

2) Cut on middle finger RT hand 2) None, watch for infection

3) Cut on Lf hand 3) None, watch for infection

4) Scattered ephelids 4) None

5) Redness due to contacts 5) None

6) Myopia 6) None

7) Dry lip tissue 7) None, just watch to see if it improves

8) Missing ant/post pharyngeal pillars from 8) None

tonsillectomy
9) None
9) Scar on bottom lip due to trauma

10) Discoloration 4-5 lingual & buccal due to amalgam

tattoo 10) None
 11) Coated tongue from coffee
11) None
12) Mouth breathing
12) Xerostomia, bad breath, progression of periodontitis
13) Occlusion- Pt is Class I for RT molar and canine and
class I for LF canine but is unclassifiable for LF molar 13) Esthetics

14) Pt has moderate, generalized biofilm

14) Calculus if not removed
15) Generalized scalloped and whitened tissue with red
tissue on 28-31 and 19-21 consistency is 15) Increased risk for gingivitis and periodontitis
edematous/spongy on 28-31 and 19-21

16) Surface texture is smooth and shiny on 19-21 and 28-

31. Surface texture of attached is generalized smooth 16) Increased risk for gingivitis and periodontitis
and shiny

17) Shape of papillae is localized bulbous n the facial of

12, 13, and 15. 17) Increased risk for gingivitis and periodontitis

18) Generalized recession on facial.

18) Periodontitis
19) Pocket depths localized 4’s on 15, 18, 2, and 3.
19) Periodontitis
20) Generalized bleeding
20) Infection, high bacteria count, calculus
21) No supparation
21) None
22) Mild horizontal bone loss on LL.
22) Periodontitis
23) Moderate horizontal bone loss UR, UL, LR
23) Periodontitis
24) Dental Charting: 1, 14, 16, 17, 19, 32 extracted. 2 O
Met rest, #3 MO met rest, #4 RCT, PFM crown,
attrition 6-11, #7 and #10 lingual Met Rest, 12 DO 24) Recurrent decay, tooth fracture, tooth pain
 TCR, 13 MOD TCR, 15 O&O TCR, 18 O MET REST,
attrition 22-27, Torsoversion distal to mesial 26, DO
TCR #29, MOD Met REST #30, #31 Gold crown.

Periodontal Case Type: Case II Plaque Score: __2.0___ Bleeding Score: __2.76___
Gingival Inflammation: Localized 28-31 and 19-21
Biofilm: Moderate generalized
Biofilm Retentive Features/Predisposing Factors: Calculus, periodontal pockets

Dental Hygiene Diagnosis

Problem Related to Risk Factors or Etiology
1) Plaque buildup, calculus, poor brushing and flossing
1) Periodontal case type 2
habits, diet, high bacteria count, Mild horizontal
bone loss on LL. Moderate horizontal bone loss UR,
UL, LR

2) Poor home care, uneducated about what causes

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

3) Recurrent caries 3) Poor home care, plaque buildup. High bacteria

count, Uneducated about how to prevent caries and
what causes this to occur

Planned Interventions
 Clinical Education Oral Hygiene Instruction

Scaling – hard deposit
removal
Polishing – soft deposit
removal
Fluoride application
1) Plaque 1) Define plaque and use flipbook page on
plaque to tach the patient how plaque is
contributing to their current calculus
deposits and past caries. Discuss the
plaque score teach and show the patient
ways to reduce the plaque score by the
next visit. Teach Bass method of brushing
and have the patient demonstrate in the
mirror what they have learned in the
session.

2) Periodontal Disease 2) Start the session by having the patient

define plaque and review the brushing
technique that we have learned at the last
session. Ask the patient how they are
doing with the Bass method of brushing
and have them show you again, make any
changes needed. Define and explain
periodontal disease and use the patients
x-rays to show bone loss, use the flipbook
page to show the progression of the
disease. Teach flossing technique using
the typodont and flipbook page. Have the
patient demonstrate the flossing
technique in the mirror.

3) Missing teeth 3) 3) Start the session by having the patient

define plaque and review the brushing
technique that we have learned at the last
session. Ask the patient how they are
doing with the Bass method of brushing
and have them show you again, make any
 changes needed. Review periodontal
disease and flossing. Make any changes as
needed. Use flipbook page define and
explain Missing teeth

Expected Outcomes
Goals Evaluation Method Time Frame
3 weeks
LTG 1: Patient will reduce the bacteria count in his mouth by 1. Plaque score evaluation at every visit using
maintaining a lower plaque score than his current score of the disclosing solution. Teach the bass method
2.0 to 1.0 in 6 weeks. of brushing and have the patient demonstrate
this method at every visit and make any changes
STG: Patient will be able to define plaque and use
needed for more effective plaque removal. Look
disclosing solution to detect plaque by his second visit.
for reduced bleeding score and check for
STG: Patient will learn the Bass method and be able to gingival inflammation
demonstrate the proper brushing technique by second visit.
STG: Patient will lower his plaque score by 0.3 each visit.
LTG 2: Patient will stop the progression of his periodontal
2. Plaque score evaluation and have the patient 6 months
disease using the techniques he will learn in patient
demonstrate the bass method of brushing that
education. Pt will lower his bleeding score from 2.76 to 2.30
he learned at the last visit. Make any changes
in 3 weeks.
necessary to improve the brushing method.
STG: Patient will be able to define periodontal disease and Teach flossing method and evaluate this at every
understand how the disease can progress by next apt. visit. Take bitewing x-rays in 6 months to check
STG: Patient will be able to demonstrate proper flossing bone levels.
technique and understand why flossing will help stop the
progression of his bone loss and periodontal disease by next
apt.

STG: Pt will lower his bleeding score by 0.3 by next apt. 6 months
3. Plaque score evaluation and have the patient
LTG 3: Patient will reduce the risk of losing more teeth by
using techniques learned in patient education.
STG: Patient will be able to understand the cause of
missing teeth and how to prevent losing more.
STG: Patient will be able to demonstrate proper brushing
and flossing technique in order to reduce his risk for losing
teeth.
STG: Patient will consider using fluoridated products to
help reduce his risk for demineralization and caries that
contribute to his loss of teeth. (Pt had pulled due to caries.)
demonstrate the bass method of brushing and
the flossing method that he learned at the last
visit. Make any changes necessary to improve
the brushing method and flossing method.
Review periodontitis. Talk about
demineralization and caries risk and fluoride.
Take bitewing x-rays in 6 months to look for any
new suspicious areas.

Prognosis Explain your prognosis

Good I believe the patient has a good prognosis. He is very concerned about his oral and overall
Fair health and I believe he will take the steps needed to stop the progression of his periodontal
Poor disease. He is very receptive and seems like he wants to learn more about his oral health.
Questionable
Hopeless

Appointment Plan
Appt # Plan for Treatment Plan for Education, Counseling or Oral Hygiene Instruction
1 Med/ Dental HX Perform chairside education about periodontitis, brushing,
Vital SIgns and flossing.
Radiographs-- FMX- phosphor plates
Intra and Extraoral Exam Plan next appointment.
Head and Neck Exam
Dental Charting
Perio Assessment
Plaque and bleeding score
Informed Consent

Define plaque and use flipbook page on plaque to tach

2 Review med/dental HX the patient how plaque is contributing to their current
Vital Signs calculus deposits and past caries.
Plaque Score/ bleeding score
Begin Scaling scale at least 2 quadrants today Class III Discuss the plaque score teach and show the patient
Patient Education Session ways to reduce the plaque score by the next visit.

Teach Bass method of brushing and have the patient

demonstrate in the mirror what they have learned in
the session.

Start the session by having the patient define plaque

3 Review med/dental HX and review the brushing technique that we have
Vital Signs learned at the last session.
Plaque Score/bleeding score
Scale at least 2 quadrants today Class III Ask the patient how they are doing with the Bass
Patient Education Session method of brushing and have them show you again,
make any changes needed.
Define and explain periodontal disease and use the
patients x-rays to show bone loss, use the flipbook
page to show the progression of the disease.

Teach flossing technique using the typodont and

flipbook page.
Have the patient demonstrate the flossing technique in

Discuss bleeding score in relation to periodontitis.
4 Review med/dental HX
Vital Signs
Plaque Score/bleeding score
Patient Education Session
Bleeding score and pocket depths
Polish (plaque free)
Floss
Apply fluoride
Referrals: None
Recall Interval: 3-4 months
the mirror.
Plan Next appointment.
Start the session by having the patient define plaque
and review the brushing technique that we have
learned at the last session.
Ask the patient how they are doing with the Bass
method of brushing and have them show you again,
make any changes needed.
Review periodontal disease and flossing. Make any
changes as needed.
Use flipbook page define and explain missing teeth.
Schedule 3-4 month Recall visit.