Patient Specific Dental Hygiene Care Plan

Patient Name ______ ____ Age ____29______ Gender: M F

Student Name ____Brittany Stollsteimer___ Date _3/7/20_

Chief Complaint: Check Up

Prophy Class_II__ Stage___1_____ Grade______A______ ASA _____II______

Assessment Findings

Medical History At Risk For

Last physical November 2019---------------------------------------- Undiagnosed health conditions and an in-office emergency
Under the care of physician------------------------------------------- None
Taking prescription medications------------------------------------- Xerostomia, caries
Past surgery, Wisdom teeth removal------------------------------- Bone resorption
Hypothyroidism---------------------------------------------------------- Increased susceptibility for infection, periodontitis, oral
candidiasis, easily bleeding gingiva, poor wound healing
Sulfa allergy causes hives---------------------------------------------- Have to stay away from certain anesthetics, possible in-office
emergency

Social and Dental History At Risk For

Drinks alcohol------------------------------------------------------------- Xerostomia, caries
Problem with previous dental treatment/ dry socket--------- Potential to get another dry socket from extraction
Gums bleed when flossing/brushing------------------------------- Severe periodontitis, infection, plaque buildup
Clenches Jaws/ Grinds Teeth----------------------------------------- TMJ issues, pain, sensitivity, waring of teeth, broken teeth
Drinks 2 sugary drinks per day--------------------------------------- Caries, Demineralization
Chews gum with xylitol------------------------------------------------- Pop out fillings, caries
 Dental Examination At Risk For
Nevi on right cheek------------------------------------------------------ Skin cancer
Mesonathic profile------------------------------------------------------- None
Scattered ephelides----------------------------------------------------- Skin cancer
Dry patch right cheek--------------------------------------------------- Skin cancer
Red/pink sclera----------------------------------------------------------- None
Tonsil stones--------------------------------------------------------------- Bad breath, sore throat, increased bacteria, tooth decay, gum
disease, oral infections
Scattered petechia on soft palate----------------------------------- None
Bilateral Torus------------------------------------------------------------ Pain from x-rays
Tight lingual frenum----------------------------------------------------- Speech issues, difficult eating, can lead to mouth breathing
which can cause caries and xerostomia
Bilateral exostosis on maxillary------------------------------------- may increase patient concern about poor aesthetics, inability
to perform oral hygiene procedures due to difficulty in cleaning
around the area with a toothbrush, and compromised
periodontal health by causing food lodgment, which could lead
to patients reporting increased bleeding when tooth brushing
Grinding/ clenching------------------------------------------------------ broken teeth, pain in jaw, attrition, recession
Right occlusion class II, left occlusion classI----------------------- Malposition in jaw, pain
Overbite 6 mm/ overjet 2 mm---------------------------------------- Gingivitis, high bacteria count, increased biofilm and calculus
Midline shift 3mm to right--------------------------------------------- Malposition in jaw, pain, broken teeth
Crowding lower anterior----------------------------------------------- Plaque buildup, caries, mispositioned teeth
Slight generalized biofilm---------------------------------------------- Gingivitis, high bacteria count, caries
Retentive features------------------------------------------------------- High bacteria count, caries
Predisposing factors----------------------------------------------------- Xerostomia, high bacteria count, caries
Localized rolled margins------------------------------------------------ Inflammation, bacteria, gingivitis
Slight recession less or at 1mm-------------------------------------- Sensitivity, caries
#31 and #18 4-5mm pocket depth---------------------------------- Gingivitis, high bacteria count, increased biofilm, and calculus
Localized bleeding #31------------------------------------------------- Gingivitis, high bacteria count, increased biofilm, and calculus
Severe attrition #6-11 & 22-27, #18 decalcification, #19 O-
TCR, #30 O-TCR and decalcification on B-------------------------- Further advancement of current decay, pain, infection, tooth
loss, larger restorations
Referral of ortho tx from Dr. Carpenter-------------------------- Will lose all enamel on anterior lingual surfaces and expose
dentin, possible teeth loss
Periodontal Case Type: 1A Plaque Score: _1____ Bleeding Score: __1.1%___

Gingival Inflammation: generalized marginal inflammation

Biofilm: slight generalized biofilm
Biofilm Retentive Features/Predisposing Factors: Malposition teeth, periodontal pockets

Dental Hygiene Diagnosis

Problem Etiology

Perio Stage I Grade A---------------------------------------------------- Plaque buildup, calculus, poor brushing and flossing habits,
diet, high bacteria count, bone loss, recession

Plaque----------------------------------------------------------------------- Poor home care, poor diet choices, uneducated about what
causes plaque buildup and how it harms the oral cavity,
bacteria

Xerostomia----------------------------------------------------------------- Medication, alcohol, diet

 Planned Interventions

Clinical Education Oral Hygiene Instruction

plaque/ brushing-------------------------------------- Define plaque and use flipbook page on plaque to teach the
Scaling – hard deposit patient how plaque is contributing to their perio. Discuss
the plaque score, teach and show the patient ways to
removal reduce the plaque score by the next visit. Teach Bass
method of brushing and have the patient demonstrate in
Polishing – soft deposit the mirror what they have learned in the session.
removal
perio 1A/ Flossing-------------------------------------- Start the session by reviewing what plaque is and how to
Fluoride application prevent it with proper brushing techniques that we learned
in the last session. Ask the patient how they are doing with
the new techniques. (Watch them demonstrate and make
any changes needed if plaque score has increased.) Define
perio and use the perio flipbook page. Teach the patient
about all the techniques she has learned will help maintain
her perio. Teach flossing and how to use a C shape around
the tooth with approximately 18 inches of floss. Get patient
to practice in the mirror.

xerostomia----------------------------------------------- Start the session by reviewing what perio disease is and

how to maintain it. Review flossing and make sure patient
is doing it properly. Ask patient how they are doing with
home oral hygiene care and if the techniques are working.
Teach patient what xerostomia. Teach her what will
happen if she doesn’t take steps to help control it. Talk to
her about drinking frequent sips of water, and avoiding
products with alcohol.
 Expected Outcomes

Goals Evaluation Method Time Frame

2 weeks
LTG 1: Patient will be able to identify what plaque is and the 1. Plaque score evaluation at every
importance of keeping a low plaque score. visit using the disclosing solution.
Teach the bass method of brushing
STG1: Patient will be able to define plaque and use and have the patient demonstrate
disclosing solution to detect plaque by her second visit. this method at every visit and make
STG2: Patient will learn the Bass method and be able to any changes needed for more
demonstrate this proper brushing techniques by second effective plaque removal.
visit.

STG3: Patient will continue brushing 2x a day for 2 mins

each time.
End of Tx
2. Plaque score evaluation and have
the patient demonstrate the bass
LTG 2: Patient will understand that she can maintain her method of brushing that she learned
perio by improving her brushing habits by the end of tx. at the last visit. Make any changes
necessary to improve the brushing
STG1: Patient will be able to define perio and understand method. Teach flossing method and
that is if an irreversible condition. evaluate this at every visit. Check
pocket depths and evaluate bleeding
STG2: Patient will be able to demonstrate proper flossing score at the last visit.
technique and understand why flossing will help prevent
progression of her perio.

STG3: Patient will begin flossing 2x a week and help

reduce her bleeding points.
6 months
3. Plaque score evaluation and have
LTG 3: Patient will understand how to help with xerostomia. patient demonstrate flossing
technique from last visit. Teach
STG1: Patient will be able to define xerostomia and how to
help prevent the risks. xerostomia and how we can help
prevent risks associated with it.
STG2: Patient will consciously drink more water by Teach patient what causes it, what
increasing her water intake by 2 cups a day. can happen if uncontrolled, and how
STG3: Patient will understand the risks that come with to maintain good oral health.
xerostomia and how to reduce them.

Prognosis Explain your prognosis

Good I believe the patient has a good prognosis. She is very concerned with her overall health and
Fair involved in her first visit. She was really concerned in learning how to prevent the progression
Poor of her perio. She was very involved in looking at her x-rays and discussing which areas have
Questionable bone loss. The patient was very interested in learning about xerostomia and is already taking
Hopeless precautions to prevent it from causing harm.

Appointment Plan

Appt # Plan for Treatment Plan for Education, Counseling or Oral Hygiene Instruction
Medical and dental history with vital signs Gather information in order to create treatment plan for this
1 Radiographs-FMX(Film) patient.
Intra and Extra Oral Exam I will develop a detailed treatment plan and gain acceptance
Dental Charting with patient to implement this plan in order to improve
Periodontal assessment patient’s oral health.
Plague and bleeding score Develop a plan to discuss with patient at following patient
Informed consent education patients.

Review medical and dental history Patient Education: Patient is going to be able to define
2 Vital signs plaque and be able to define and demonstrate proper
Plaque Sore brushing techniques
Begin Scaling max R possibly Mand R I will demonstrate the Bass Method for patient on typodont
Patient education session and then I will have patient demonstrate this skill on
typodont.
 Scale this quad I will then disclose patient at mirror and have them
Possibly this quad demonstrate the new brushing Bass Method that was just
taught. I will evaluate the patient by redisclosing and
together we will look in mirror to determine how much
plaque was removed.
We will return to table and review anything the patient may
have questions on. State we are a team and we will work
together.
Scale Max R

Begin patient education by asking patient if they can define

3 Review medical and dental history plaque and to describe the Bass Method that was taught last
Vital signs time.
Plaque score Patient Education: Patient will be able to define perio and
Bleeding score and pocket depths what causes it. They will understand that it is irreversible
Discuss flossing but can be maintained. Patient will be able to properly floss.
Scale Mand R hopefully Max L I will review the patient’s plaque score and determine if it
has improved or not.
Scale this quad I will teach the patient proper flossing technique (spool or
Scale this quad loop technique)
Patient will then at mirror be disclosed and demonstrate the
technique that was just learned. I will redisclose and
together we will determine how well they did this skill.
We will return to table and re-discuss what was taught
I will inform patient that we are working as team and always
let know I am always here for him.
Scale Mand R and Max L
Begin patient education by reviewing both skills (brushing
Review Medical/Dental History
and flossing).
Plaque Score I will ask patient to define plaque and perio and what causes
4 it.
Patient Education Session
Discuss plaque score.
Complete Scaling Will teach patient xerostomia and how to reduce risks
Discuss xerostomia involved
 Patient will understand that she can be more prone to caries
Plaque free and Fluoride
and other oral health issues if uncontrolled.
Patient will start taking precautions to prevent severe
xerostomia and risks.
Scale Man L if have not yet

Scale this quad

Referrals: orthodontic treatment

Recall Interval: 4-6 months