Patient Specific Dental Hygiene Care Plan

Patient Name: --------------- Age: 54 years Gender: M F

Student Name: Sukirti Misra Date: 03/28/2018

Chief Complaint: Dental cleaning Prophy class: 3 Perio class: 3

Assessment Findings

Medical History At Risk For

19. Last physical: July 2017 None

23. Under the care of a physician for Diabetes, Hypertension and

Thyroid disease
 Antihypertensive medications: Benazepril, Amlodipine. Xerostomia, altered taste sensation, dizziness, nausea, vomiting,
 Diabetes medications: Metformin. heartburn, weight gain, constipation, somnolence
 Thyroid disease: Levothyroxine
 Folic acid Hypoglycemia

27. Previous surgeries: Tonsils (1971), Adenoids (1971), Sinus surgery Infection
(1994), Tube pulled (1996)
46. Diabetes Type 2 Gingivitis, periodontitis, xerostomia, high risk for cavities, altered taste

72. Hypertension Heart attack, stroke, aneurysm, heart failure

80. Thyroid disease Goiter, cancer

Other significant medical conditions: Fibromyalgia Muscle pain

GERD Esophagus lesions, ulcers, cancers
Severe migraine Stroke
Social and Dental History At Risk For

88. Last dental visit was in 03-2017 for teeth cleaning Periodontal disease, undiagnosed caries, undiagnosed oral diseases

91. Last x-rays done in February 2018 None

94. Clenching Attrition, tension headache, sensitivity, sore TMJ

98. Decreased salivary flow (dry mouth) Caries, infection

99. Sugar containing diet or sport energy beverages: less than 2-3 Caries, hypersensitivity
per week
Dental Examination At Risk For

Body type: Obese Heart disease, Type 2 Diabetes

Mild hearing loss Etiology- Idiopathic Cognitive function, poorer mental health, social withdrawal, positive
correlation with dementia
Mesognathic profile None

Spider vein (broken blood vessels) both sides on the cheeks and chin. Swelling and bruising, change in skin sensation, infection,
Etiology- sun damage hyperpigmentation, scarring

Wears corrective lenses: Myopia. Etiology- developmental None

Tonsils removed surgically None

Cheeks bites bilateral Ulcers, infection

Slight Bilateral mandibular tori. Etiology- developmental Inflammation

Decreased salivary flow. Etiology- medications Caries, infection

Molar occlusion Right: Class I Interference with eating, malocclusion, plaque retention
Left: Class I with tendency for II
Canine occlusion: Right – Class I Malocclusion
Left- End on end
Architecture: Scalloped (generalized); Flat (mandibular anteriors) Plaque retention
Gingiva: Color- Pink; Marginal gingiva is red generalized Periodontitis
Consistency- edematous/spongy Periodontitis
Texture- smooth and shiny (generalized); Stippled Periodontitis
Shape of margins- Rolled, generalized Periodontitis
Shape papillae- Bulbous in mandibular anteriors, facial side Periodontitis
Bleeding- Generalized bleeding on probing Periodontitis, infection, tooth loss due to mobility, calculus build up
Position of the margin (recession): Generalized Periodontitis, infection, tooth loss due to mobility, calculus build up and
root caries
Pocket Depths: 1-4mm- generalized; 5mm- max molars and #18; Periodontitis, infection, tooth loss due to mobility, calculus build up
6mm- #31,32

Mild Horizontal bone loss: #3,4, 12,13,14,15 Periodontitis, bone loss, increased periodontitis if not stopped
Moderate Horizontal bone loss: #4,6 Periodontitis, bone loss, increased periodontitis if not stopped and may
lead to tooth loss

Mild Vertical bone loss: # 31,31,32 Periodontitis, bone loss, increased periodontitis if not stopped and may
lead to tooth loss
Widened PDL: Generalized Periodontitis
Loss of crestal bone: Generalized Periodontitis, bone loss, increased periodontitis if not stopped and may
lead to tooth loss

Calculus: #15,18 Periodontitis, tooth loss

Metallic restorations on # 3,14,15,18,19,20,29,30,31,32 Recurrent caries

TCR restorations on #7,8,9 Discoloration, recurrent caries

Caries on #4, 19 Pulpal involvement if left untreated, tooth pain

Generalized moderate biofilm and calculus Periodontitis, caries

And localized heavy (mandibular posteriors, lingual side)
Periodontal Case Type: 3 Plaque Score: 2.1 Fair Bleeding Score: 28%

Gingival Inflammation: Generalized Marginal and Papillary (Mandibular anteriors)

Biofilm: Generalized Moderate, Localized Heavy (Mandibular posteriors-lingual surface)
Biofilm Retentive Features/Predisposing Factors: Calculus, malpositioned teeth, periodontal pockets, systemic disorders and medications

Dental Hygiene Diagnosis

Problem Etiology

1. Plaque Improper technique of brushing, Bacteria present in plaque and

calculus causes periodontal disease. Xerostomia, treatment-induced.
History of poor oral hygiene.
Infrequent professional dental cleaning.
 2. Periodontitis Improper brushing and flossing. Bacteria present in plaque and calculus
may lead to progression of disease process. Positive co-relation with
Diabetes.
Prolonging dental visits may lead to progression of Periodontitis.

3. Type 2 Diabetes Improper diet, genetics

VVVVV
 Planned Interventions

Clinical Education Oral Hygiene Instruction

Scaling – hard deposit 1. Plaque: Define plaque- white, sticky substance 1. Teach proper brushing technique (modified Bass).
removal consists of bacteria and food debris. Importance of Brush for at least 2 minutes, 2x a day with a soft
removing plaque to prevent gingivitis, caries and toothbrush or electric toothbrush.
Polishing – soft deposit halting the progression of periodontitis.
removal Importance of maintaining good home care to
reduce plaque accumulation.
Importance of regular dental visits and cleaning (3-
Fluoride application
4 months).

2. Periodontitis: Define Periodontitis- inflammation 2. Teach flossing technique. Instruct patient to floss
of the supporting structures around the tooth. It is every day. Recall 3-4months for cleaning.
irreversible because of bone loss (bone will not
regrow on its own).
Importance of flossing- explain how toothbrush
cannot clean in between teeth surfaces, therefore
brushing alone is not sufficient. Mouth feels fresh
after flossing.

3. Type 2 Diabetes: explain the negative effects of
the disease and explain how the medications
affect oral cavity such as xerostomia, caries.
Discuss ways to decrease the effects of
xerostomia. Importance of sugar substitutes and
fluoride use.
3. Discuss correlation between Diabetes and gum
disease (periodontitis). Diabetic patient is at a higher
risk to develop advanced gum disease
(periodontitis). This is more likely to happen in
poorly controlled blood glucose levels. Similarly,
having serious gum disease may cause diabetes
harder to control. Suggest salivary flow substitutes
such as Biotene for xerostomia.
 Expected Outcomes

Goals Evaluation Method Time Frame

LTG: 3-4 months
LTG 1: Patient will lower plaque score to 1.5 (Good) or less by next 1. Observe while brushing. Take plaque score at each
appointment in 3-4 months. visit. Ask questions about plaque and review
STG: End of
patient’s knowledge of plaque control.
STG: Patient will define Plaque by second appointment. treatment
STG: Patient will demonstrate correct brushing technique
(Modified Bass) by second appointment.
STG: Patient will reduce plaque score by 0.5 at each
appointment (until it reaches 0.5 or less).

LTG 2: Patient will halt progression of Periodontitis by next 2. Take Bleeding score at each visit. Examine LTG: 3-4 months
appointment in 3-4months. interproximal areas for plaque. Ask questions
about flossing habits, adjust goal as needed. STG: End of
STG: Patient will define Periodontitis by third appointment. treatment
STG: Patient will demonstrate proper flossing method by third
appointment.
STG: Patient will decrease bleeding score by 10% or more at each
visit (until it reaches 1% or lower)
 LTG: 3-4 months
LTG 3: Patient should have increased awareness of the 3. Assess salivary flow at each appointment.
negative effects of diabetes to oral health by next STG: End of
appointment in 3-4 months. treatment
STG: Increase the knowledge of correlation between Type 2
Diabetes and Periodontitis by the end of treatment.
STG: Increase the knowledge of dry mouth and its effects by end
of treatment.
STG: Increase the knowledge of salivary substitutes and fluoride
use by end of treatment.

Prognosis Explain your prognosis

Good
Fair
 Poor Patient has a history of periodontitis, several restorations and tooth loss. There is moderate periodontitis
Questionable with several teeth having recession. There is a history of improper plaque control and infrequency of dental
Hopeless visits. Dental professional and patient will have to work as a team to reduce patient’s plaque and bleeding
score. Patient will need encouragement to keep up with regular dental visits. Reiterate the importance of
regular dental visit at each appointment.
 Appointment Plan

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

1 Update Med/Dent history and complete required paperwork. Define Plaque.

Pre-rinse. Head/neck and intraoral exam, periodontal Discuss importance of plaque control by home care and regular
assessment, dental charting, treatment plan and risk dental visits. Emphasize dental visits every 3-4 months.
assessment. Take Plaque and bleeding score. Patient Explain disease processes caused by plaque accumulation.
education. Scale UR quad. Educate patient on proper tooth brushing technique.
X Evaluate patient’s brushing method, correct if needed.

2 Update Med/Dent history. Pre-rinse. Take Plaque and bleeding
score. Patient education. Scale LR quad.
Quick review of brushing from last visit.
Define Periodontitis.
Educate patient on proper technique to floss and maintenance of
good oral hygiene to stop progression of this disease. Set goal for
patient to floss everyday using the correct technique.
Evaluate patient’s flossing technique and correct if needed.

x
 3 Update Med/Dent history. Pre-rinse. Take Plaque and bleeding Quick review of periodontitis and flossing.
score. Patient education. Scale UL and LR quads, plaque free Define Diabetes. Explain the negative effects of the disease and
and fluoride treatment. explain how the medications affect oral cavity such as xerostomia,
caries. Discuss ways to decrease the effects of xerostomia.
X Importance of sugar substitutes and fluoride use.
Recap instruction needed to improve the overall oral health and set
X up for a 3-4 month recall.

Referrals: General dentist for caries and prosthodontist for missing teeth
Recall Interval: 3-4 months