Date: 11/7/2019 DMACC

Student Name: Danielle Teachout Dental Hygiene

Patient Name: Restu A.
DOB: 09/13/1969 Treatment Plan
Medical History & Medications: ASA Physical Status Dental History: Occlusion:
      Classification: History of amalgam and composite Bilateral Tend. Class III
ASA 1 restorations. Endodontic therapy on #7.
Implant on #19.
Developmental Abnormalities & Restorative Problems: Other: Radiographic Evidence:
Defects: No current areas of active       FMX previously exposed at the
None decay Iowa City school of dentistry.
Decay not detected of
radiographs. Radiographic bone
loss detected.

Risk Factors are as follows (be specific).

1. Systemic Health: Good 3. Caries No active decay
CVD: None Sugar Intake: Moderate
Diabetes Mellitus: None Streptococcus Mutans Count: 370
Respiratory Disease: None Plaque-Removal Ability: Patient is physically able to
remove plaque but lacks the
educations of importance and
options of plaque removal.
Osteoporosis: None Socioeconomic Status: Middle Working Class
Preterm Low Birth Weight: None Plaque Retentive Factors: Patient does have some
restorations making it easier for
plaque retention. Heavy calculus
present serves are host of bacteria
adhesion.
Behavioral Status: None Fluoride History: Patient does not have history of
fluorinated water as a child.
Patient currently drinks
fluorinated tap water and uses a
fluoride toothpaste.
Psychosocial Status: Dental Anxiety Past & Present Caries Activity: Experience with dental
restorations. No current
detectable areas of decay.

1
 Medication Considerations: Patient is taking over the Other:      
counter medications : Vitamin
E 180 mg, Vitamin D3 2000
iu, and Ibuprofen as needed
for pain management.
Other:      
4. Periodontal Disease: Localized severe with 13 sites of
bleeding
2. Oral & Pharyngeal Cancer: None (host environmental risk factors/indicators)
Tobacco Use: None Previous History of Disease: History exposure of latent
tuberculosis found in dental
records from Iowa City.
Race: Filipino Classification of Disease(s): Latent
Alcohol Use None Clinical Attachment Loss: Loc Sev
Sun Exposure: Patient is an immigrant from Stress Factors
The Philippines with heavy
sun exposure. Patient currently
works in a green house with
moderate sun exposure.
Pathology: No pathology findings at the PHP: PHP ranges between .5 and 1
appointment.
Other:       PBI: Moderate
Deposits Classification: Class V
Bacterial Pathogens: Carries Screen : 370
s. mutans and p. gingivalis
Tobacco Use: None
Glycemic Control N/A
Inherited Risk Unable to determine
Other: CAMBRA- Low Risk

2
Date: 11/07/2019
Student Name: Danielle Teachout
Patient Name: Restu A.
DOB: 09/13/1969

Diagnostic Decision Making

Eight Human Needs Related to Oral Health & Disease
Assessment (check signs and symptoms present)
1. Wholesome Facial Image 5. Freedom from Head and Neck Pain
Teeth Gingiva Facial Profile Extra-/intra-oral pain or sensitivity
Breath Other:       Other:      

2. Freedom from Anxiety/Stress 6. Biologically Sound & Functional Dentition

Reports or Displays: Reports difficulty in chewing
Anxiety about proximity of clinician confidentiality or previous Presents with:
dental experience. Defective restorations Ill-fitting dentures, appliances
Oral Habits Substance Abuse Teeth with signs of disease Abrasion erosion
Missing teeth Rampant caries
Concern about: Other:     
Infection control, fluoride therapy, fluoridation, mercury toxicity

3. Skin & Muccous Membrane Integrity of Head & Neck 7. Responsibility for Oral Health
Extra/intra-oral lesion Pockets greater than 4mm Plaque and calculus present
Swelling Attachment loss greater than Inadequate parental supervision of oral health care
4mm No dental exam within the last 2 years
Gingival inflammation Xerostomia Other:      
Bleeding on probing Other:      

4. Protection from Health Risks 8. Conceptualization & Understanding

BP outside of normal limits Need for prophylactic antibiotics Has questions about DH care and/or oral disease
Potential for injury Risk Factors Other:      
Other:      
3
Date: 11/7/2019
Student Name: Danielle Teachout
Patient Name: Restu A.
DOB: 09/13/1969

1. Initial Review Statement (chief concern, patient wants and expectations):

Restu A. is a middle-aged woman and is a United States Immigrant currently living in Pella, IA. My patient appears to be in good health. Restu is
fluent in speaking English. My patient has not had a dental cleaning in many years. Her chief complaint is that she dislikes the appearance of her
teeth. She also experiences extreme dental anxiety. She is not currently taking any medications prescribed from a physician Restu is aware that she
needed to improve her dental care but was not aware that she needed to have deep cleaning. There is moderate gingival swelling and moderate
bleeding on probing. Clinical attachment loss places Restu in a localized severe periodontal classification. Her plaque removal is good. My patient
does not have a home dentist and typically uses the University of Iowa and Des Moines Area Community College for dental care. She is aware that
due to the heavy calculus and deep pocket depths she will require multiple appointments of scaling and root planning. Restu is aware the she will
need anesthesia to removal all subgingival calculus.     

2. Hypotheses (differential diagnosis):

Moderate PHP Score
Moderate PBI Score
Clinical Attachment Loss
Loc Sev Periodontitis
Probing depths over 4
Toothbrush Abrasion
Radiographic Calculus
Moderate plaque accumulation
Overhand margins of restorations
Poor home care
No dental home
Amalgam tarnishing
Possiable decay and abscess      

3. Inquiry Strategy:
Review Health History
Address Patients Chief Complaint
Monitor patients’ vital signs
Extra Oral Exam
Intra Oral Exam
Dental Charting
4
PHP
PBI
Full Mouth Probe
Full Mouth Radiographs
Calculus Detection
Full Mouth debridement
Sulcular lavage with cavitron
CHX Rinse
6 week re-eval
3 month periodontal maintenance
Amalgam polishing
Etiology of gingivitis
Etiology of periodontal disease
Etiology of dental caries
Prognosis of Periodontal Disease
Education of needle stick
Education of lingual anterior toothbrush technique
Education on sulcular toothbrush technique
Education of use of soft toothbrush use
Education of proxy brush use for interproximal care
Education of electric toothbrush
Education of waterpik
Education of Fluoride Varnish
Education to patient of numbness after admin of local anesthetic- watch for cheek bites
Education to patient of using an Anti-inflammatory such as ibuprofen after SRP appointments

5
Date: 11/07/2019
Student Name: Danielle Teachout
Patient Name: Restu A.
DOB: 09/13/1969

4. Dental Hygiene Diagnosis (list the human need not met, then be specific about the etiology & signs & symptoms evidencing a defect) :

Unmet Human Need Etiology Signs & Symptoms

Wholesome Facial Image- Teeth Periodontal disease Heavy Plaque Accumulation
Mesial shift Heavy Calculus Accumulation
Lack of regular home DDS Marginal Overhang on Restorations
No previous orthodontics Mandibular Crowding
Recurrent Decay
Food Impaction
Wholesome Facial Image- Gingiva Ineffective toothbrushing Bleeding on Probing
Lack of interproximal cleaning Clinical Attachment Loss
Lack of dental knowledge Recession
Lack of professional dental care
Irritation from plaque and calculus
Wholesome Facial Image- Facial Profile No previous orthodontics Crowding
Mesial shift Malocclusion
Lack of professional dental care Mesial drift of #31
Personal feelings of what teeth should look like
Freedom from Anxiety/Stress- Anxiety of Local Prior Dental Trauma Increased heart rate
Anesthetic Lack of dental knowledge Increase respiratory rate
Mental Disorder- Anxiety Cold palms
Skin & Muccous Membrane Integrity- Bleeding Ineffective toothbrushing Bleeding on Probing
on Probing Lack of interproximal cleaning Bleeding on Debridement
Lack of dental knowledge Bleeding on Calculus detection
Lack of professional dental care
Lack of dental insurance
Skin & Muccous Membrane Integrity- Pockets Periodontal disease Deep probing depths
greater than 4mm Attachement Loss Recession
Lack of regular home DDS
Lack of interproximal cleaning

Skin & Muccous Membrane Integrity- Periodontal disease Probing depth over 5
Attachment loss greater than 4mm Attachement Loss CAL above 10 on less than 30% of teeth

6
 Lack of regular home DDS
Lack of interproximal cleaning
Biologically Sound and Functional Dentition- Lack of regular home DDS
Missing Teeth Dental Decay
Lack of dental knowledge
Lack of professional dental care
Biologically Sound and Functional Dentition- Lack of dental knowledge
Abrasion Poor toothbrushing habits
Use of Hard Toothbrush    #14
High sugar content diet   
Responsibility for Oral Health-Plaque and Lack of dental knowledge
Calculus Present Lack of professional dental care
Lack of interproximal cleaning
Ineffective toothbrushing
Responsibility for Oral Health- no dental cleaning Lack of regular home DDS
within the last 2 years Lack of dental knowledge
Conceptualization & Understanding- Has Lack of dental knowledge
questions about DH care
7
Teeth #1, #15, #16, #17, and #30 have been
extracted
#19 replaced with implant
Severe Recession on #13 and #14
Tooth structure loss on cervical third of #13 and
Failure to have professional dental cleaning
Class V Calculus
Heavy Plaque interproximal
Review of health history. Patient has been to
DDS for treatment of implant but has not had a
professional dental cleaning in over 2 years
Patient inquiries about Cavitron use and
Amalgam polishing
 Jointly Determined Treatment Plan
Date: 11/07/2019
Student Name: Danielle Teachout
Patient Name: Restu A.
DOB: 09/13/1969
Patient Goals Educations and Treatment Evaluation
(Target etiologies) (goal met, partially met or unmet)

8
Apt #: 1- Assessment & SRP of
lower anterior
Date: 11/07/2019
Time Req: 4 Hours
1) Pt will consent to treatment 1) Obtain pt consent for 1. Patient consents to
2) Pt will provide a treatment and record in chart treatment- Goal met
comprehensive health history, 2) Review pt health history 2. Patient provided full health
including health conditions, 3) Obtain pt dental history and history- Goal met
allergies, medications. prior treatments she has had 3. Patient provided full dental
3) Pt will provide a dental 4) Educate patient on history- Goal met
history including past appointments, importance of checking vital signs 4. Patient agrees with
Past radiographs taken and any before treatment along with normal importance of vital signs- Goal met
anxieties toward the appointment. range and above normal BP 5. Patient placed arm out and
4) Pt will show understanding 5) Take pt BP and record in consented to having vital signs
of importance of checking vital signs chart taken- Goal met
before appointment. 6) Ask the pt if she has any 6. Patient explains chief
5) Pt will consent to having chief complaints today, record in complaint- Goal met
blood pressure and pulse taken chart 7. Patient shows understanding
before appointment. 7) Educate the patient the of CHX rinse- Goal met
6) Pt will report chief complaint purpose of using CHX rinse prior to 8. Patient washes with CHX
is there is any the appointment rinse- Goal met
7) Pt will understand 8) Give directions and cup of 9. Patient agrees to wear
importance of CHX rinse CHX to pt napkin. Patient places on safety
8) Pt will consent to CHX rinse 9) Explain purpose of eye wear glasses- Goal met
9) Pt will consent to wear the and napkin to pt. Provide them to the 10. Patient showed
patient napkin and eye protection pt to wear during the appointment understanding of EIE exam. Patient
10) Pt will consent to EIE exam 10) Explain to the pt the purpose give consent- Goal met
11) Pt will understand findings of an EIE exam 11. Patient understands EIE
of EIE exam 11) Educate pt on any EIE findings- Goal met
12) Pt will consent to dental findings 12. Patient understands hard
charting 12) Explain the purpose and tissue findings- Goal met
13) Pt will understand importance of having a current 13. Patient understands purpose
importance of a full mouth probe dental chart on file of full mouth probe- Goal met
evaluation and consent 13) Explain to the pt the process 14. Patient understands what
14) Pt will show understanding and purpose of preforming a full normal pocket depth is. Patient
of probing depths mouth probe understands her current pocket dept-
15) Pt will show understanding 14) Explain to pt probing depths Goal met
of PBI score are above normal indicating 15. Patient understands their PBI
16) Pt will understand purpose of attachment loss score. Patient understands the
disclosing solution 15) Educate the pt on bleeding meaning of gingivitis and possiable
17) Pt will consent to using during probing indicates active periodontal disease- Goal met
disclosing agent infection of gingivitis 16. Patient understanding
18) Pt will observe disclosed 16) Explain to the pt the purpose disclosing agent- Goal met
9
areas in hand mirror
19) Pt will understand PHP score
20) Pt will discuss homecare
routine she is currently using
21) Pt will learn proper TB
techniques
22) Pt will understand
recommendation to brush gently
with soft toothbrush twice a day to
remove food debris and plaque
accumulation.
23) Pt will demonstrate proper
TB techniques while using the hand
mirror
24) Pt will understand the term
calculus and its contributions to
periodontal disease and gingivitis
25) Pt will consent to full mouth
explore to find calculus and
possiable dental caries
26) Pt will understand meaning
of deposit classification score
27) Pt will understand
importance of having full mouth
radiographs on file before full
treatment can begin
28) Pt will have full mouth
survey sent to DMACC clinic before
a full mouth SRP
29) Pt will understand and
consider all options for treatment
and what will happen without
treatment., number of appointments,
costs included
30) Pt will agree to receive SRP
treatment in quadrants, have a 6-
week re eval and maintain
maintenance appointments every 3
months.
10
and importance of using a disclosing
agent to identify the plaque
accumulating on the teeth
17) Apply disclosing solution to
all the teeth and record score in chart
18) Give patient the hand mirror
for her to view the areas she is
missing
19) Educate the pt that she is
missing many areas while brushing
20) Talk to the patient about her
current home care routine-
evaluating her current state of
change in homecare
21) Educate the pt on turning the
toothbrush vertically to reach the
lingual mandibular anterior.
22) Educate the pt that switching
to a soft TB will prevent any more
abrasion on 13 and 14
23) Give pt a soft TB and hand
mirror to demonstrate the prior
education
24) Educate the pt on the
etiology of calculus and its
contributions to periodontal disease
and gingivitis
25) Educate the pt on the process
and purpose of a full mouth explore
to find calculus and possiable dental
caries
26) Educate the pt that she has
significant calculus accumulation on
more than 30% of her teeth
27) Educate the pt on the reasons
why we need full mouth radiographs
on file before we can complete SRP
28) Note in the pt chart that she
will have the radiographs sent over
17. Patient consents to PHP test-
Goal met
18. Patient uses hand mirror to
view areas that have disclosed- Goal
met
19. Patient understands how we
reached current PHP score by using
the hand mirror- Goal met
20. Patient describes current
homecare- Goal Met
21. Patient uses hand mirror to
observe brushing vertically- Goal
met
22. Patient understands
switching to a soft toothbrush- Goal
met
23. Patient uses toothbrush to
show proper toothbrush technique-
Goal met
24. Patient understands what
calculus is and why regular
cleanings are important for oral
care- Goal met
25. Patient understands that
calculus will build all around the
mouth. Patient will see the explore.
Patient will consent to calculus
detection- Goal met
26. Patient understands current
calculus score- Goal met
27. Patient understands the
importance of having a FMX on file
before full treatment can begin-
Goal met
28. Patient has FMX sent over
from Iowa City - Goal met
29. Patient understands treatment
options and progress of disease
without treatment- Goal met
 31) Pt will understand that we
will only be able to complete SRP
on 22-27 and wait to continue until
radiographs are rcvd
32) Pt will understand the
importance of intra oral
photographs  chart for full mouth SRP, 6 week re
33) Pt will consent to intraoral
photographs
34) Pt will understand the
importance of using local anesthetic
during todays cleaning
35) Pt will consent to the
administration of local anesthetic
36) Pt will consent to using
cavitron and hand instruments
37) Pt will understand post-op
directions and pain management
38) Anti-inflammatory such as
ibuprofen after SRP appt.
Apt #: 2- SRP #32- #28, UR 1) Pt will consent to treatment
Date: 11/14/2019 2) Pt will provide a
Time Req: 4 Hours comprehensive health history
3) Pt will consent to having
blood pressure and pulse taken
11
by next appointment.
29) Educate the pt of all options
for treatment and what will happen
without treatment., number of
appointments, costs included
30) Establish treatment plan in pt
eval, and all maintenance
appointments.
31) Educate the pt that we will
start treatment today of the lower
anterior only. Once we receive her
FMX we will continue with
treatment- note in chart
32) Educate pt on process and
purpose of intraoral photographs
33) Give the pt cheek retractors
and preform a full intraoral
photograph- record in chart
34) Educate pt in importance of
administration of local anesthetic
during today’s cleaning
35) Give pt instructions to follow
during the administration of local
anesthetic- record in pt chart
36) Explain to the pt the purpose
and benefits of using cavitron and
hand instruments- record in pt chart
37) Educate the pt on possiable
post op sensitivity in the treatment
areas
38) Educate the pt to take an
Anti-inflammatory such as
ibuprofen after today’s SRP appt
1) Obtain pt consent for
treatment and record in chart
2) Review pt health history
3) Take pt BP and record in
chart
30. Patient agrees to establishing
a treatment plan- Goal met
31. Patient agrees to start
treatment today on the lower
anterior- Goal met
32. Pt will understand the
importance of intra oral
photographs- Goal met
33. Pt uses cheek retractors for
intra oral photos- Goal Met
34. Pt understand the importance
to using local anesthetic and
consents- Goal met
35. Pt follows directions during
the injection- Goal met
36. Pt understands the process
and importance of using the
cavitron- Goal met
37. Pt understands that she may
be sensitive after treatment – Goal
met
38. Pt understand that if she
experiences pain she will use an
anti-inflammatory for pain control-
Goal met
1. Patient consents to
treatment- Goal met
2. Patient provided full health
history- Goal met
3. Patient placed arm out and
before appointment.
4) Pt will report chief complaint
is there is any
5) Pt will consent to CHX rinse
6) Pt will consent to wear the
patient napkin and eye protection
7) Pt will consent to EIE exam
8) Pt will consent to using
disclosing agent
9) Pt will observe disclosed
areas in hand mirror
10) Pt will understand PHP score
11) Pt will discuss homecare
routine she is currently using
12) Pt will understand the
recommendation of using a proxy
brush for interproximal care
13) Pt will understand the
diagnosis of periodontal disease
14) Pt will understand the term
calculus and its contributions to
periodontal disease and gingivitis
15) Pt will consent to the
administration of local anesthetic
16) Pt will consent to using
cavitron and hand instruments
17) Pt will understand the
incident of a needle stick during
admin of local anesthetic along with
blood born illnesses
18) Pt will consent blood test at
Unity Point with results in 24 hours
19) Pt will understand there were
5 additional teeth that will need to be
rescaled at next appointment
20) Pt will understand post op
pain management with anti-
inflammatory’s such as ibuprofen
after SRP appointments
12
4) Ask the pt if she has any
chief complaints today, record in
chart
5) Give directions and cup of
CHX to pt
6) Provide pt with safety
glasses and pt napkin
7) Preform EIE exam and
educate pt on any EIE findings
8) Apply disclosing solution to
all the teeth and record score in chart
9) Give patient the hand mirror
for her to view the areas she is
missing
10) Educate the pt where the
disclosing solution is accumulating
11) Talk to the patient about her
current home care routine-
evaluating her current state of
change in homecare
12) Educate the pt on using a
proxy brush to clean interproximal
13) Dentist comes to review
radiographs sent over from Iowa
City, diagnosing Periodontal
disease. Educate pt on etiology of
periodontal disease
14) Educate the pt on the
etiology of calculus and its
contributions to periodontal disease
and gingivitis
15) Give pt instructions to follow
during the administration of local
anesthetic- record in pt chart
16) Explain to the pt the purpose
and benefits of using cavitron and
hand instruments- record in pt chart
17) Educate the pt on the
incident of the needle stick while
consented to having vital signs
taken- Goal met
4. Patient explains chief
complaint- Goal met
5. Patient washes with CHX
rinse- Goal met
6. Patient places on safety
glasses- Goal met
7. Patient understands EIE
findings- Goal met
8. Patient consents to PHP test-
Goal met
9. Patient uses hand mirror to
view areas that have disclosed- Goal
met
10. Patient understands how we
reached current PHP score by using
the hand mirror- Goal met
11. Patient describes current
homecare- Goal Met
12. Patient understands the use
of trying a proxy brush- Goal met
13. Pt understands the diagnosis
of periodontal disease- Goal met
14. Pt understand the etiology of
the disease- Goal met
15. Pt follows directions during
the injection- Goal met
16. Pt understands the process
and importance of using the
cavitron- Goal met
17. Pt understands how the
incident of the needle stick occurred
along with possiable transfer of
blood born pathogens- Goal met
18. Pt has blood drawn at Unity
Point- Goal met
19. Pt understand that we need to
stop treatment today – Goal met
 administrating local anesthetic along 20. Pt understands that she may
with blood born illnesses be sensitive after treatment and she
18) Explain to the pt that we will will use an anti-inflammatory for
need to attend Unity Point Clinic for pain control- Goal met
a blood test
19) Explain to the pt that due to
the needle stick we will need to stop
treatment today to attend the
appointment at Unity Point. Inform
her that we will continue treatment
of those teeth at the next
appointment- record in chart
20) Educate the pt on possiable
post op sensitivity in the treatment
area. Advised the patient take an
Anti-inflammatory such as
ibuprofen after today’s SRP appt
Apt #: 3- SRP #21-#18, UL 1) Pt will consent to treatment 1) Obtain pt consent for 1. Patient consents to
Date: 11/26/2019 2) Pt will provide a treatment and record in chart treatment- Goal met
Time Req: 4 Hours comprehensive health history 2) Review pt health history 2. Patient provided full health
3) Pt will consent to having 3) Take pt BP and record in history- Goal met
blood pressure and pulse taken chart 3. Patient placed arm out and
before appointment. 4) Ask the pt if she has any consented to having vital signs
4) Pt will report chief complaint chief complaints today, record in taken- Goal met
is there is any chart 4. Patient explains chief
5) Pt will consent to CHX rinse 5) Give directions and cup of complaint- Goal met
6) Pt will consent to wear the CHX to pt 5. Patient washes with CHX
patient napkin and eye protection 6) Provide pt with safety rinse- Goal met
7) Pt will consent to EIE exam glasses and pt napkin 6. Patient places on safety
8) Pt will consent to using 7) Preform EIE exam and glasses- Goal met
disclosing agent educate pt on any EIE findings 7. Patient understands EIE
9) Pt will observe disclosed 8) Apply disclosing solution to findings- Goal met
areas in hand mirror all the teeth and record score in chart 8. Patient consents to PHP test-
10) Pt will understand PHP score 9) Give patient the hand mirror Goal met
11) Pt will discuss homecare for her to view the areas she is 9. Patient uses hand mirror to
routine she is currently using missing view areas that have disclosed- Goal
12) Pt will understand the 10) Educate the pt where the met
recommendation bass tb method disclosing solution is accumulating 10. Patient understands how we
towards gingiva on all posterior 11) Talk to the patient about her reached current PHP score by using
13
molars
13) Pt will understand the term
calculus and its contributions to
periodontal disease and gingivitis
14) Pt will consent to the
administration of local anesthetic
15) Pt will consent to using
cavitron and hand instruments
16) Pt will understand the use of
Oraquix anes. Gel on #8
17) Pt will consent to the use of
Oraquix anes. Gel
18) Pt will understand that she
may be numb for awhile and to
watch for cheek bites
19) Pt will understand the large
dark areas on her teeth are tarnished
amalgam
20) Pt will understand the
treatment option of amalgam
polishing at 6 week recall
appointment
21) Pt will understand post op
pain management with anti-
inflammatory’s such as ibuprofen
after SRP appointments
14
current home care routine-
evaluating her current state of
change in homecare
12) Educate the pt on applying
the bass TB method toward the
gingiva on all posterior teeth
13) Educate the pt on the
etiology of calculus and its
contributions to periodontal disease
and gingivitis
14) Give pt instructions to follow
during the administration of local
anesthetic- record in pt chart
15) Explain to the pt the purpose
and benefits of using cavitron and
hand instruments- record in pt chart
16) Educate the pt on using
Oraquix anes. Gel to prevent another
injection
17) Administer Oraquix followed
by a well rinse of the area
18) Educate the pt that due to
admin of LA throughout the mouth
she may experience numbness
around her mouth and to watch for
self-mutilation of cheek and lips
19) Educate to the pt the large
dark areas she see are tarnished
amalgam fillings
20) Explain to the patient the
process of amalgam polishing that
can be completed at next
appointment
21) Educate the pt on possiable
post op sensitivity in the treatment
area. Advised the patient take an
Anti-inflammatory such as
ibuprofen after today’s SRP appt
the hand mirror- Goal met
11. Patient describes current
homecare- Goal Met
12. Pt understands the Bass TB
method- Goal met
13. Pt understand the etiology of
gingivitis and periodontal disease-
Goal met
14. Pt follows directions during
the injection- Goal met
15. Pt understands the process
and importance of using the cavitron
and hand instruments- Goal met
16. Pt understand the use of
Oraquix – Goal met
17. Pt consents to the use of
Oraquix, record in chart- Goal met
18. Pt understands that because
we gave many injections today she
will experience numbness after the
appointment- Goal met
19. Pt understands the dark areas
are tarnished amalgam fillings- Goal
met
20. Pt understands that we can
polish the tarnished fillings at the
next appointment- Goal met
21. Pt understands that she may
be sensitive after treatment and she
will use an anti-inflammatory for
pain control- Goal met
Apt #: 6 Wk Re-Eval 1) Pt will consent to treatment 1) Obtain pt consent for 1. Patient consents to
Date: 1/21/2020 2) Pt will provide a treatment and record in chart treatment- Goal met
Time Req: 2 Hr comprehensive health history 2) Review pt health history 2. Patient provided full health
3) Pt will consent to having 3) Take pt BP and record in history- Goal met
blood pressure and pulse taken chart 3. Patient placed arm out and
before appointment. 4) Ask the pt if she has any consented to having vital signs
4) Pt will report chief complaint chief complaints today, record in taken- Goal met
is there is any chart 4. Patient explains chief
5) Pt will consent to CHX rinse 5) Give directions and cup of complaint- Goal met
6) Pt will consent to wear the CHX to pt 5. Patient washes with CHX
patient napkin and eye protection 6) Provide pt with safety rinse- Goal met
7) Pt will consent to EIE exam glasses and pt napkin 6. Patient places on safety
8) Pt will consent to using 7) Preform EIE exam and glasses- Goal met
disclosing agent educate pt on any EIE findings 7. Patient understands EIE
9) Pt will observe disclosed 8) Apply disclosing solution to findings- Goal met
areas in hand mirror all the teeth and record score in chart 8. Patient consents to PHP test-
10) Pt will understand PHP score 9) Give patient the hand mirror Goal met
11) Pt will understand the for her to view the areas she is 9. Patient uses hand mirror to
recommendation of using an electric missing view areas that have disclosed- Goal
toothbrush 10) Educate the pt where the met
12) Pt will understand the disclosing solution is accumulating 10. Patient understands how we
treatment of prophy polishing 11) Educate pt on the benefits of reached current PHP score by using
13) Pt will consent to prophy using a hand held waterpik the hand mirror- Goal met
polishing 12) Educate pt on the importance 11. Patient understands the
14) Pt will understand the large for plaque removal for management benefits of using a waterpik - Goal
dark areas on her teeth are tarnished of periodontal disease Met
amalgam fillings 13) Educated pt on the etiology 12. Pt understands the
15) Pt will understand the of Periodontal disease, Dental Decay importance of proper interproximal
treatment option of amalgam and Gingivitis care for management of periodontal
polishing 14) Educated pt on FM Probe to disease- Goal met
16) Pt will consent to amalgam access attachment level after SRP 13. Pt understand the etiology of
polishing 15) Obtain consent for FM Probe gingivitis and periodontal disease-
17) Pt will understand the from pt and record in chart Goal met
importance of Fluoride Varnish 16) Educate the pt on calculus 14. Pt understands the purpose of
18) Pt will consent to Fluoride detection a full mouth probe- Goal met
Varnish 17) Obtain consent for calculus 15. Pt consents to Full Mouth
19) Pt will understand post op detection from pt and record in chart Probe- Goal met
pain management with anti- 18) Educate pt on benefits at 16. Pt understands that she has
inflammatory’s such as ibuprofen using cavitron for cleaning and some new calculus forming- Goal
15
 after SRP appointments consent met
19) Educate pt on selective 17. Pt consents to calculus
polishing and consent detection, record in chart- Goal met
20) Educate pt the benefits of 18. Pt understands the process
topical fluoride varnish. Consent and importance of using the cavitron
from pt and apply varnish and hand instruments- Goal met
21) Explain again etiology of 19. Pt understands selective
gingivitis and periodontal disease polishing- Goal met
and purpose of 3 month SPM appts 20. Pt understands the benefits of
22) Educate pt treatment process, applying fluoride varnish, pt
number of appointments and the cost consents- Goal met
included 21. Pt understands etiology of
gingivitis and periodontal disease
and why she needs to maintain 3
month SPM- Goal met
22. Pt understands the treatment
process and cost of the
appointments- Goal met
Apt #: 3 Month SPM 9) Pt will observe disclosed 1) Obtain pt consent for Future appointment- Goals not met
Date: TBD areas in hand mirror treatment and record in chart yet
Time Req: 2 Hr 10) Pt will understand PHP score 2) Review pt health history
11) Pt will understand the 3) Take pt BP and record in
recommendation of using a waterpik chart
to clean interproximal 4) Ask the pt if she has any
12) Pt will understand the chief complaints today, record in
importance of removing plaque daily chart
to control periodontal disease 5) Give directions and cup of
13) Pt will understand CHX to pt
Periodontal Disease, Dental Decay, 6) Provide pt with safety
and Gingivitis glasses and pt napkin
14) Pt will understand Full 7) Preform EIE exam and
Mouth Probe educate pt on any EIE findings
15) Pt will consent to Full Mouth 8) Apply disclosing solution to
Probe all the teeth and record score in chart
16) Pt will understand calculus 9) Give patient the hand mirror
detection for her to view the areas she is
17) Pt will consent to calculus missing
detection 10) Educate the pt where the
18) Pt will consent to the use of a disclosing solution is accumulating
16
 cavitron and hand instruments 11) Educate pt on the benefits of
19) Pt will consent to prophy using a handheld waterpik
polishing 12) Educate pt on the importance
20) Pt will consent to Fluoride for plaque removal for management
Varnish of periodontal disease
21) Pt will understand the 13) Educated pt on the etiology
diagnosis of periodontal disease of Periodontal disease, Dental Decay
22) Pt will understand that and Gingivitis
treatment, number of appointments 14) Educated pt on FM Probe to
and cost included access attachment level after SRP
15) Obtain consent for FM Probe
from pt and record in chart
16) Educate the pt on calculus
detection
17) Obtain consent for calculus
detection from pt and record in chart
18) Educate pt on benefits at
using cavitron for cleaning and
consent
19) Educate pt on selective
polishing and consent
20) Educate pt the benefits of
topical fluoride varnish. Consent
from pt and apply varnish
21) Explain again etiology of
gingivitis and periodontal disease
and purpose of 3month SPM appts
22) Educate pt treatment process,
number of appointments and the cost
included
Apt #:                        
Date:      
Time Req:      
Apt #:                        
Date:      
Time Req:      
Apt #:                        
Date:      
Time Req:      
17
18