Patient Specific Dental Hygiene Care Plan

Patient Name: Age 28 Gender: M F

Student Name: Abigail Maxwell Date 2/26/2019

Chief Complaint: cleaning & x-rays

Prophy Class: 2 Perio Class: 2

Assessment Findings

Medical History At Risk For

1. Last Physical: N/A 1. Undiagnosed medical problems

2. Buprenorphine: taken once daily; maintenance 2. Headache, nausea, vomiting, sweating, constipation,
treatment of opioid dependence insomnia; signs and systems of withdrawal; xerostomia

3. C-section 2010 3. Possible future complications. No current complications

4. Cholecystectomy 2012 4. Difficulty digesting food, diarrhea, bile leak, bleeding,

infection, pancreatitis; No current complications
5. Allergy: Morphine
5. Hypersensitivity reaction, anaphylactic reaction- rash,
6. Treatment for alcohol and drug dependency swelling
6. Relapse; symptoms of withdrawal; higher risk for
infection/disease, immunocompromised, slower recovery
rate

Social and Dental History At Risk For

1. Last dental visit: 02/05/2017 1. High bacteria count, calculus buildup, caries
 2. Type and date of most recent x-rays taken: N/A 2. Undiagnosed dental problems

3. Gums bleed when flossing
4. Prone to many cavities at dental checkups
5. 3 sugary/sports drinks a day
3. Gingivitis, infection, high bacteria count, periodontal
disease, interproximal caries
4. Gingivitis, infection, high bacteria count, periodontal
disease, interproximal caries

5. Caries, demineralization

Dental Examination At Risk For

1. Sthenic 1. None

2. Mesognathic 2. None

3. Raised papule lower right chin eti: bacteria 3. Infection

4. Bilateral submandibular lymphadenopathy, moveable 4. Infection

eti: idiopathic
5. TMJ pain, tenderness, headache
5. TMJ deviation to the right; bilateral popping eti:
idiopathic 6. Future complications, no current complications

6. Slight palatal tori; slight unilateral mandibular tori eti:
developmental
7. Coated tongue posterior dorsal surface eti: sinus
drainage
7. Hight bacteria count, increased biofilm, calculus,
gingivitis, periodontitis, oral cancer, defective
restorations, demineralization
8. None

8. Class I occlusion R/L molar; Class I occlusion R/L canine 9. Malocclusion, esthetics, TMJ complications

9. Overbite: 2mm and Overjet 3mm Midline shift: 2mm to

the right
 10. Moderate generalized biofilm 10. High bacteria count, increased biofilm, calculus, gingivitis,
periodontitis, demineralization, caries
11. Rolled tissue- mandibular posterior facial
11. Periodontitis, high bacteria count, increased biofilm,
12. Generalized recession #4, #5, #12, #13, #20, #21, #28, calculus buildup
#29
12. Periodontitis, infection, increased biofilm, calculus,
13. Generalized 4mm pocket depths bleeding, defective restorations, demineralization, caries

14. No suppuration 13. Periodontitis, infection, increased biofilm and calculus,

calculus deposits, bleeding
15. Generalized BOP #30, #3, #24, #23, #20
14. None
16. Localized Horizontal bone loss lower anterior #24, #25,
#28, #29 15. Gingivitis, high bacteria count, increased biofilm and
calculus
17. Root dilaceration #3, #1
16. Recession, periodontitis, calculus buildup
18. TCR: #2 w/ recurrent decay, #3, #14 w/ recurrent
decay; Sealant: #1 17. Future complications

19. Incisal attrition on #8, #9 18. Recurrent decay

20. Mesial incisal fracture #8 19. Tooth decay, excess wear on incisal edge

21. Caries: #1MO, #2MO/DO, #3M, #4F, #11F, #12 MODF, 20. Sensitivity, tooth decay, esthetics
#14MO, #18M, #19DO, #20DO, #21F, #29F, #30MODF
21. High bacteria count, increased biofilm, calculus, gingivitis,
periodontitis, demineralization

Periodontal Case Type: 2 Plaque Score: 2.33 Fair Bleeding Score: 2.87%

Gingival Inflammation: N/A

Biofilm: Generalized moderate
Biofilm Retentive Features/Predisposing Factors: Calculus, Caries, Nutrition
 Dental Hygiene Diagnosis

Problem Etiology

1. Periodontal Case Type 2- Slight Periodontitis Plaque buildup, poor brushing and flossing methods, behavioral
factors, high bacteria count, recession, TMJ complications, caries,
infection, disease progression

2. Plaque/Calculus Poor homecare, poor brushing, Pt. does not floss

3. Poor Diet/Caries Poor eating habits; lessen sugar intake and frequent snacking on
cariogenic foods/drinks to reduce caries
 Planned Interventions

Clinical Education Oral Hygiene Instruction

Plaque/Brushing Define what plaque is using flipbook. Have the
Scaling – hard deposit patient understand plaque is “white sticky”
removal bacteria that forms on our teeth. If plaque is not
removed the proper way, it could lead to future
Polishing – soft deposit problems. Demonstrate the proper brushing
removal technique, bass method, and have pt. practice in
mirror. Take a plaque score to show spots that
Fluoride application were missed when brushing. Modify technique as
needed.

Periodontitis/Flossing Have pt. recall what plaque is and how to properly

brush using bass method. Explain periodontitis
with pt. and its involvement with soft tissue and
bone. When plaque is left untreated, the
surrounding structures are affected which can
result in loose teeth. Explain that it is irreversible
but as a team we can halt the progression of the
disease. It is her job though to brush properly and
visit the dentist every 3- 4 months. Introduce
correct flossing method. Educate pt. to
understand flossing reduces the chance of her
caries progressing. Have patient demonstrate and
help as needed.

Caries/Fluoride Review pt.’s understanding of plaque,

periodontitis, brushing, and flossing techniques.
Explain how caries prevention revolves strongly on
nutritional habits. Using Flipbook define caries and
what causes caries. Show how much sugar is
consumed in soda and how the acidic features are
 what is demineralizing the enamel and forming
caries on patient’s teeth. Use of fluoride will be of
importance to remineralize enamel and prevent
the progression of caries. Discuss patients’ diet
and make suggestions. Also use radiographs to
point out pt.’s interproximal caries.

Expected Outcomes

Goals Evaluation Method Time Frame

LTG 1: Pt. started with a plaque score of 2.33 and will aim to 1. Define plaque. A plaque score will be
End of 1st
lower plaque score to 1 or less. evaluated at every appointment using
Apt.
disclosing solution. Teach bass method
STG 1: Patient will be able to define plaque and use
and have patient demonstrate at every
disclosing solution to determine where plaque buildup is by
appointment. Make changes if needed to
the 2nd visit.
produce a better plaque score.
STG 2: Patient will learn bass method and how this
technique will reduce plaque. She will be able to demonstrate
by the 2nd visit on herself and the typodont
STG 3: She will reduce her bacteria count in the mouth by
lowering her score .3 at each appointment visit until she
reaches a plaque score of one or less
LTG 2: Patient will achieve to stop the progression of her End of 2nd
2. Recap plaque and brushing learned from
periodontal disease Apt.
last appointment. Define periodontal
STG: Patient will be able to identify periodontal disease and disease and use current x-rays to help
understand that it is irreversible. explain bone loss. Teach flossing method
and evaluate to make any changes. Take
STG: Patient will demonstrate proper flossing technique
FMX and use x-rays to visually explain
learned in pt. ed. and understand why flossing is important
bone loss and point out dark spots
to halt the progression of bone loss and reduce interproximal
indicating caries between teeth.
caries
 3. Recap flossing and periodontal disease
STG: Patient will decrease bleeding point score by 2nd visit
and set up recall appointment in the next 3-4 months.
LTG 3: Patient will be educated on how her diet and
nutritional habits are the cause of her caries
STG: Patient will be able to describe the caries process by
understanding what affects caries has on the teeth and how
they are formed on the teeth.
from previous appointment. Discuss how
diet can affect her teeth and the cause of
her caries. Define caries and explain the
importance of fluoride for it will help End of 3rd
remineralize those areas. Also advise pt. Apt.
to snack to on non-cariogenic foods
instead.

STG: Patient will set a goal to limit her frequent snacking on

sugary, cariogenic foods.
STG: Patient will state the importance of fluoride and use it
at least once a day

Prognosis Explain your prognosis

Good I believe my patient has a fair prognosis. She is aware that her oral health and overall health are
Fair of concern. Patient says she wants her mouth to be healthier and assures that she is willing to
Poor make new steps to stop progression of her periodontal disease and is anxious to be referred to a
Questionable dentist to treat her caries. Patient is interested in learning more about nutrition and its effects
Hopeless on her teeth.

Appointment Plan

Appt # Plan for Treatment Plan for Education, Counseling or Oral Hygiene Instruction
Medical/Dental hx Data Collection
1 Radiographs- FMX
Intra and Extra Oral Exam
Dental Charting
Periodontal Assessment
Bleeding Score/Plaque Score
Informed Consent
 Medical/Dental hx
2 Bleeding Score/Plaque Score
Sickle Scale Evaluation
Scale Maxillary Rt/Lt Quadrant
Medical/Dental hx
3 Bleeding Score/Plaque Score
Scale Mandibular Rt/Lt Quadrant
Plaque Free
Floss
Fluoride
Medical/Dental hx
4 Patient Ed Session
Referrals: Caries #1MO, #2MO/DO, #3M, #4F, #11F, #12 MODF, #14MO, #18M, #19DO, #20DO, #21F, #29F, #30MODF
Recall Interval: 3-4months
UR UL Discuss plaque score and teach patient how to reduce this
score by next visit. Discuss how plaque causes diseases such
as gingivitis and periodontitis if left untreated. Teach bass
method and have patient demonstrate at every appointment.
Make changes as needed to produce a better plaque score.
Use disclosing solution to determine where plaque buildup is
located and spots the patient is missing.
Review patient’s knowledge from last session. Redefine
plaque and tooth brushing method used. Introduce today’s
LR LL topics of periodontitis and flossing. Have patient demonstrate
flossing technique (Spool method) and discuss how we need
to halt her progression of periodontitis because it is an
irreversible disease.
Review plaque, brushing, flossing, periodontal disease and
caries in relation to diet. Restate longer-term and short-term
goals. Encourage! Encourage! Encourage! Congratulate the pt.
on any accomplishments thus far
Have patient know her recall time is 3-4 months to closely
observe her periodontal disease.
Check that goals were attained and review all lessons.
Schedule 3-4 month recall visit