Patient Specific Dental Hygiene Care Plan

Patient Name: ------------------- Age: 23 Gender: F

Student Name: Paula Philpott Date : 2/22/17

Chief Complaint: Cleaning & x-rays

Assessment Findings

Medical History At Risk For

Pt. has no physician nor dentist----------------------------------------- Any systemic diseases such as periodontitis, gingivitis
Last physical. Jan. 2016--------------------------------------------------- NONE

Social and Dental History At Risk For

83. Tobacco products: Vapor 2-3 times daily w/nicotine--------- Chemicals entering the airways of the lungs
85. Alcoholic beverages once weekly---------------------------------- Xerostomia, cancer, gingivitis, caries
88. Last dental visit: 2011 for a cleaning------------------------------ Plaque build up, caries, gingivitis, periodontitis
91. X-rays: FMX 2010, BWX Feb 2017, PANO Feb 2017----------- NONE
92. Gums bleed when brushing and flossing------------------------- Gingivitis
93. Teeth sensitivity to hot, cold, sweets, pressure---------------- Caries
97. Pt. has many cavities when visiting dentist--------------------- Caries, gingivitis, periodontitis
99. Patient drinks 4+ sugary drinks daily------------------------------ Caries, plaque build up, staining, gingivitis
 Dental Examination At Risk For
Asthenic body type--------------------------------------------------------- NONE
Skin/Nails: dry, peeling etio: dry skin & weather------------------- NONE
Hair/Scalp: dry etio: weather-------------------------------------------- NONE
Profile: Mesoganathic------------------------------------------------------ NONE
Skin: Scattered Ephilides etio: developmental & macule on
right side of cheek regular border etio: sun exposure ------------ Skin Cancer
nevi: Right side of neck below chin, regular border, rough -
raised papule: etio: developmental------------------------------------ Skin Cancer
Eyes: Corr. Lenses, Myopia etio: developmental------------------- NONE
Commissures of lips: dry cracked etio: weather-------------------- NONE
TMJ Sounds: popping no sound etio: developmental------------- Atrrition, abfraction, bruxism, tooth sensitivity
Hard Palate Rugae: Dark brown spots etio: Vaping, smoking--- Infections, bacteria, cancer
Mucosa: Materia alba etio: Trauma from occlusion--------------- Infection, bacteria
Mucosa: Vesicle mand. right below maxillary lab frenum------- Infection, bacteria
Frena: Extra tissue- Etio: idiopathic------------------------------------ NONE
Occclusal Exam: Lft & Rt Molar & Canine Class 1------------------- NONE
Overbite 3mm, Overjet 3mm, midline shift 2mm to left--------- Crowding, caries, plaque buildup
Soft tissue Color: Generalized red------------------------------------- Gingivitis, periodontitis, infection, bacteria , bleeding, sensitivity
Soft tissue consistency: Endematous/Spongy: mand Lingual &
Max/Mand incisors facial-------------------------------------------------- Gingivitis, Periodontitis
Soft tissue Shape, papillae Bulbous generalized---------------------- Gingivitis, periodontitis, suppuration, sensitivity
Soft tissue shape, Margins: rolled generalized----------------------- Gingivitis, periodontitis, sensitivity
Pocket depths: localized 4-6 mm pocket depths-------------------- Gingivitis/Periodontitis
Localized bleeding #2,15,18,31------------------------------------------ Gingivitis
Dental Charting: PE of #1, 16 molars, IMP #17, 32
Hypocalcification on #2-15 incisal edges, attrition on
#6,7,8,9,10,11, 20,23,24,25,29 incisal edge, SA on
2,3,14,15,18,31,-------------------------------------------------------------- Restorative care, removal of 3rd molars for risks of infection
Home Care: MED. Bristled toothbrush, Stillman brushing
method, brushing only in AM, No flossing, no rinsing, 3D white
toothpaste w/ fluoride----------------------------------------------------- Toothbrush abrasion, increase in caries, gingivitis, periodontitis,
calculus build up
Periodontal Case Type: Case 1 Plaque Score: 4.6 (poor) Bleeding Score: 4.7619%
Gingival Inflammation: Generalized Marginal
Biofilm: Moderate Generalized
Biofilm Retentive Features/Predisposing Factors: Calculus, Malpositioned teeth, Caries, Tobacco use (vaping)

Dental Hygiene Diagnosis

Problem Related to Risk Factors or Etiology

1. Results to calculus then demineralization then caries.

Due to infrequent Dental visits, poor hygiene, bacteria
1. Plaque
2. Periodontitis
3. Vaping 2. Bleeding gums, loss of attachment, Halitosis, periodontal
4. Caries pockets, gingivitis leading to periodontitis. Periodontitis
5. TMJ is irreversible, but can be halted.

3. Chemical burn, xerostomia, halitosis, coughing, caries,

periodontitis. Due to vaping bacteria.

4. Demineralization of tooth, loss of tooth, fillings, root

canal. Due to plaque and calculus build up, poor hygiene,
infrequent dental visits, bacteria.

5. Sore jaw, trouble chewing due to limitations of joint,

tired and overworked muscles. Due to clenching and
grinding.
 Planned Interventions

Clinical Education Oral Hygiene Instruction

1. Plaque
Scaling hard deposit -Describe what it is (sticky deposits of 1. -Brushing mechanically 2X a day
removal bacteria) -Flossing
-What it looks like (sticky, clear film, food
Polishing soft deposit debris) 2. -Brushing 2X a day
removal -How to remove it (brushing, flossing) -Flossing
-What it causes (if left to harden it -Professional cleaning every 3-4 months
Fluoride application becomes calculus, If not cleaned then the
gums will get irritated which leads to 3. - Brushing 2X a day
gingivitis. -Chew gum with xylitol instead of vaping
2. Periodontitis -Tobacco Cessation methods
-Describe what it is (bacterial infection
caused by plaque, loss of attachment of
tooth from socket)
-What it looks life (puffy, red gums that
easily bleed)
-What it causes (if not halted, it can lead
to loss of overall tooth)
3. Vaping
-What it is (whats in vapes)
-What it causes (xerostomia, chemical
burn, caries, halitosis, coughing,
periodontitis)

Expected Outcomes
 Goals Evaluation Method Time Frame
@ 3rd
LTG 1: To reduce plaque score to .1 or less 1.Take plaque score at every visit
appointment/ End
STG: Define Plaque of treatment
STG: Define Brushing (2x a day)
STG: Help brush with correct brushing style @ 3rd
LTG 2: Halt progression of periodontitis. 2 .Take new bleeding score/visual appointment/ End
inspection of gums. of treatment
STG: Define periodontitis and (gingivitits)
STG: Demonstrate flossing (2X a day)
STG: Reduce bleeding score by 1.0 each appointment.
3. Annual oral exams, check for chemical
LTG 3: Quit the use of Vaping. Tobacco cessation
burns and possible caries.
STG: Educate damages of vaping. in 1 year
STG: Vape 1-2x a day
STG: Vape 0-1x a day

Prognosis Explain your prognosis

Good Patient shows self interest in progressing towards meeting the goals we both discussed. I feel
Fair the patient will have awareness of the information & know what it is, but is not planning on
Poor starting the goals. Patient doesnt seem to put forth effort in changing her brushing technique
to the bass method nor correctly flossing or brushing twice daily.
Questionable
Hopeless
 Appointment Plan

Appt # Plan for Treatment Plan for Education, Counseling or Oral Hygiene Instruction
Dental/Med History Define Plaque
1 Take Plaque/bleeding score Teach Patient how to properly brush and floss
Patient Education Watch Patient brush
Pre-Rinse Adjust/reeducate brushing & flossing if needed
Scaled UR

Dental/Med History Define Caries

2 Take Plaque/bleeding score Teach patient about diet, pH levels, acid attacks (pH 4.4-5.5
Patient Education over a period of time)
Pre-Rinse Find DDs, discuss payments, scheduling appointment
Scaled UL Adjust/reeducation anything from previous session

Dental/Med History Define Tobacco

3 Take Plaque/bleeding score Teach patient about harmful effects of tobacco
Patient Education Tobacco cessation
Pre-Rinse Risk if patient does not quit
Scaled LR Adjust/reeducation anything from previous session

Dental/Med History Adjust/reeducate anything from previous session

4 Take Plaque/bleeding score
Patient Education
Pre-Rinse
Scale LL
Plaque Free
Fluoride
Referrals: For DDS for restorations
Recall Interval: 3-4 months