Stefanie Fischer

Dental Hygiene Treatment Plan #2

1. Assessment
a. This patient is an Asian male in his twenties. There is nothing significant in his
health history.
b. Patient is taking no medications. Patient says he experiences some sensitivity to
cold and notices bleeding gums. He does not see a dentist regularly as of now. He
had oral surgery 20 years ago. Patient states he uses a hard bristle tooth brush and
crest tooth paste. He did not know what floss was when asked if he flosses. He
drinks more bottled water than tap water. He does not snack much in between
meals.
c. Does not use drugs or use alcohol excessively.
d. BP: 106/78
e. Extra Oral Exam: Noted severe acne, greasy hair, breath odor. Slight clicking with
right and left movement of the jaw, but never experienced any problems, pain or
difficulty in opening, closing or chewing. All else WNL. Intra Oral Exam:
Chapped lips, tonsils present, erupting third molar, maxillary and mandibular
exostosis, and white tongue coating. All else WNL. Moderate brown extrinsic
staining on the lingual sides of the anterior teeth. Color of the gingiva was
generalized pink but red in color localized to the anterior teeth. The contour of the
interdental papilla was generalized pointed/normal. The contour of marginal
gingiva was generalized knife-edged and rolled localized to the canine areas. The
consistency of gingiva was generalized firm and resilient. The texture of gingiva
was generalized stippled. Bleeding on probing was spontaneous. Plaque score was
63% on March 12, 2014 and 36% on April 11, 2014.

f. No probing depths were recorded for this patient, he was seen before we began
periodontal probing in clinic (and the diagnosis does not pertain to perio disease).
g. Four bite wings were taken March 6, 2014. There are no significant findings
regarding the gingivitis of this patient.
2. Diagnosis
a. The main concern for this patient is generalized gingivitis.
3. Plan
a. No consultations necessary.
b. Treatment goals: remove bacteria from plaque and calculus, reduce inflammation
in gingiva, and to educate the patient in oral hygiene.
c. Preliminary phase refers to assessment data collection, see part 1 named
assessment. Phase one is the therapy phase. This will involve dental biofilm
control, discussing preventive measures and calculus removal. Dental biofilm will
be assessed using the plaque score. Dental biofilm will be removed through
scaling, polishing and flossing. Preventive measures will be introduced. A fluoride
tray with foam fluoride will be applied for four minutes. Listerine mouth wash
will be recommended for daily use to help with the bacteria causing his gingivitis.
He consumes a lot of meat and does not snack much so we will need to discuss
his coffee or soda habits. Calculus will be assessed using calculus detection of the
Ramford teeth with an explorer. Calculus will be removed using an ultrasonic
scaler, sickle, Gracey , Gracey 11/12, and Gracey 13/14. The outcomes of the
therapy phase to be evaluated are clinical signs of inflammation, dental biofilm
control and patient participation. Phase two is the surgical phase, which this
patient does not need. Phase three is the restorative phase, which is also not
needed by this patient. The evaluation of overall outcomes will be evaluating
periodontal response to restorations or implants. This patient does have
restorations, but does not have any implants. Phase four is the maintenance phase.

This includes further appointments for continuing care and supervision as well as
reviewing and practicing proper oral hygiene. The status of his gingiva will need
to be checked in detail to determine the improvement or worsening of the
gingivitis. We need to discuss and review the C shaped method for flossing. He
has a difficult time with floss so I will provide him with samples of interproximal
brushes as well as wooden picks for the purpose of interproximal cleaning in
hopes that one option will work better for him on a daily basis.
d. My role as a hygienist is to provide my patient with the best possible care and
treatment during our appointments. I will accomplish this through OHI, hand
scaling, ultrasonic debridement, polishing, and fluoride trays. My patients role is
to comply with OHI given to him: flossing once daily, brushing with a soft
bristled toothbrush using the BASS brushing method, rinsing with water after
meals and using Listerine mouth rinse once a day.
4. Implementation
a. Ultrasonic, sickle, Gracey , Gracey 11/12, Gracey 13/14, explorer.
b. Ultrasonic debridement, hand scaled full mouth, polished full mouth with Colgate
sensitive prophy paste, flossed full mouth, applied fluoride trays.
c. Homecare aids: floss, floss picks, interproximal brushes and Listerine mouth
wash.
d. Used topical anesthetic on lingual mandibular anterior teeth because of sensitivity.
e. No prescriptions were written.
5. Evaluation
a. Plaque score improved from 63% on March 12, 2014 to 36% on April 11, 2014.
There was some improvement in the color of the gingiva and bleeding has
decreased slightly.
b. He does not need radiographs again because patient just had radiographs
completed March 6, 2014.
c. Sensitivity has decreased slightly; however, it is still present. There is still heavy
bleeding of the gums, but his oral hygiene skills have improved immensely as

shown by the improved plaque score. He is using a soft bristled tooth brush, using
the BASS brushing method, beginning to floss, and using Listerine mouth wash.
References:
Wilkins, Esther. (2013). The dental hygiene care plan. Clinical Practice of the
Dental Hygienist. (351-360).
Crossley, H.L, Meiller, T.F. & Wynn, R.L. (2013). Drug Information Handbook
for Dentistry.