CARE PLAN TEMPLATE

Care Plan submission will use findings from included patient information.
Student Name _______________Taylor Maass_____________________________________
Patient Name______Candice Cass____________________________________Age__25_____
Chief Complaint: _______” My gums bleed all the time” __________________________

1. Medical History: (list any positive medical history findings from the medical & social history.
Correlate the finding places the patient at risk for.)
Medical History Findings At Risk For:______________
14 weeks pregnant Drowsiness, weakness, loss of
prenatal vitamins and cyclizine Coordination, nausea, dry mouth
constipation and blurred vision due
to her medication. Periodontitis,
gingivitis, enamel erosion,
Poor hygiene due to fatigue

2. Dental History: (List past and/or present dental disease, the chief complaint, and the present
oral hygiene habits. Correlate the effects on periodontal diagnosis, and/or care)
Dental History Findings At Risk For:_____________
Patient states that her “gums bleed all the time” Caries, Gingivitis, and Periodontitis,
Many cavities decreased morale for homecare,
Suspicious areas in the mouth TMJ problems, attrition, recurrent
Xerostomia caries, sensitivity, prolonged healing
Class II calculus supra and subgingival
Bruxism TMJ problems, attrition,
malpositioning of teeth

3. Oral Examination: (List the positive findings, habits and awareness. Correlate the effects on
periodontal diagnosis)
Oral Examination Findings At Risk For:___________
Lower labial mucosa magenta and reddened Gingivitis, possible infection
Tonsils removed Periodontitis/ possible infection
Reddened area bilateral anterior tonsillar pillar peritonsillar abscess
Enlarged thyroid hormonal imbalance/
nnnnnnnnnnnnnnnnnnnnnnnnnn. . Undiagnosed hypothyroidism
Popping and clicking of TMJ Possible jaw complication> surgery

4. Periodontal Examination: (make a statement regarding the color, contour, texture,

consistency, general biofilm locations, biofilm retentive features, predisposing factors to biofilm
retention, overall pocket depths, bone loss, make reference to location of bleeding sites, etc.)
Patient has generalized moderate marginal and papillary redness with edematous papilla,
localized severe edematous papilla between #29 and 30. Generalized interproximal 4mm
pocket depths with localized 5mm between # 29 and 30. No recession present, no furcation’s or
mobility. Bleeding everywhere except anterior maxillary teeth. More bleeding on anterior
mandibular due to lingual retainer. Bleeding score 75% and plaque score 55%. Light
supragingival and subgingival calculus deposits.

a. Periodontitis Stage: _I___ Periodontitis Grade: _A___

b. Plaque Score: __2.2_or 55%_ Evaluation of plaque score: __Fair_______
c. Bleeding Score: __75%____ Evaluation of bleeding score:_Poor,_generalized >30%_
5. Dental Charting Examination: (List all findings from dental charting exam. Examples are
caries, attrition, midline position, occlusion, abfractions, etc. Correlate to effect on periodontal
diagnosis, progression, and/or care)
Dental Charting Findings: At Risk For:___________________
Class I malocclusion left and right caries
Composite restoration on #3, 14, 19,30 recurrent decay/sensitivity
Missing tooth # 1,5,12,16,17,21,28 and 32 Shifting of teeth, change of occlusion
Suspicious areas- 4 MOD, 5 DO, 29 DO, 30 MOD Caries/ caries progression

6. Radiographic Findings: (List the conditions such as crown to root ratio, bone loss, condition
of interproximal bony crests, thickened lamina dura, calculus, and root resorption)
Radiographic Findings:___________________________At Risk For:_________________
No crystal bone loss Caries
Suspicious areas- 4 MOD, 5 DO, 29 DO, 30 MOD Recurrent decay/pain

7. Dental Hygiene Diagnosis: (List all of the dental hygiene related problems associated with
this patient, with each problem list the etiology)
Dental Hygiene Problem: Etiology:_________________
Gingivitis Improper brushing/ flossing technique
bbbbbbbbbbbbbbbbbhormonal imbalance due to pregnancy
Sugar intake, xerostomia
Nausea pregnancy
Xerostomia medication side effect
Recurrent decay improper brushing/ flossing.
demineralization due to vomiting/ diet

8. Treatment/Appointment Plan: (Include assessment findings of patient needs,

appropriate treatment, and education plan- include long and short term goals) Each long term
goal should be supported by at least 2 short term goals.
Appointment 1:
Plan for Treatment: Goals: Plan for Education and/or Oral
 Medical dental history,
address chief complaint:
bleeding gums, take intraoral
pictures of bleeding gums,
take x-rays, take plaque and
bleeding score, patient
education and instruction
session, cleaning disclosing
solution, fluoride application,
deep cleaning, root planing/
scaling on right maxillary and
right mandibular quadrants
______________________________________________________Hygiene Instruction
Appointment 2:
Plan for Treatment: Goals:
______________________________________________________Hygiene Instruction
Update medical dental Session 2 LTG: reduce caries
history, take intraoral by proper brushing/ flossing
LTG: get patient to change
her brushing and flossing
technique and frequency to
arrest her gingivitis by her
final recall appointment
STG 1: patient will
understand that certain
brushing techniques are
more effective and how this
will improve her bleeding
gums. This will be done by
the end of the appointment.
STG 2: patient will
understand the importance
of flossing daily and use the
correct technique. This will
be done by the end of the
appointment patient will try
to brush twice a day.
STG 3: Patient will decrease
bleeding score by 10% every
recall appointment every 1
month
Plan for Education and/or Oral
Begin patient ed session 2 by
reviewing the previous
For the first patient
education session we will
focus on the topics of
brushing, flossing, gingivitis,
and plaque. We will make
sure the patient is aware that
pregnancy can induce
gingivitis and periodontitis
due to hormonal imbalance.
She will know that this can
induce early labor and that it
is important that we get this
taken care of.
We will educate the patient
on proper brushing
techniques and flossing
techniques and the
importance of flossing daily.
We will report the patient’s
plaque and bleeding score
and set short- and long-term
goals that will address her
chief complaint. Take
intraoral pictures to compare
future progress and take x-
rays to assess bone loss.
Probe the mouth and show
the patient the bleeding
points on the chart and
pocket depth at the dental
chair.
pictures of bleeding gums,
take plaque and bleeding
score, patient education and
instruction session #2, scale
and root plane left
mandibular and left maxillary
quadrants.
technique. Also, have teeth
restorations done in one
year.
STG 1: have one cavity filled
every month
STG 2: lower sugar intake by
eating less sugary foods at
parties to help reduce overall
caries.
session and reviewing
previous skills. Report to the
patient what their plaque and
bleeding score for that day
are. Review goals from
Session 1 and determine if
patient achieved those short-
term goals Provide positive
feedback. If patient did not
reach the goals, why? Provide
additional instructions to
assist patient in achieving.
Proceed into Patient Ed
session 2 by explaining
caries, fluoride, mouth rinse
and plaque. Review what the
STGs will be and how they
will help the patient achieve
the desired outcome. Use
patient’s intraoral pictures as
visual aides to show
inflammation inside the
mouth. Then use patient’s
probe chart as a visual aide to
show pocket depths &
bleeding points. Discuss what
the patient’s own bleeding
score means related to the
amount of inflammation. Use
the patient's x-rays as a visual
aid to show bone loss if any .
Reinforce the importance of
thorough plaque removal
daily. Introduce and
demonstrate the floss
threaders as an aide for
interproximal plaque
removal. First demonstrate
the use of the floss threaders
on a typodont. Explain to the
patient that this is the proper
way for her retainer.. Allow
patient to answer open-ended
questions to assess her
understanding of gingivitis
and inflammation. Ask
 patient to demonstrate the
floss threader on the typodont
and assess her understanding
of the skill. Invite patient to
the sink, disclose the patient
and ask her to look in the
mirror and identify areas in
her mouth where there is
interproximal plaque
remaining. Ask the patient to
remove those areas of plaque
using the floss and floss
threaders. Observe & assess
her ability to use the floss
threader in her own mouth.
Redisclose the patient and ask
her to look in the mirror and
see if she was able to remove
the areas of interproximal
plaque. Compliment the
patient and provide positive
reinforcement. Return to the
patient ed table and review
the session, asking open
ended questions. Determine if
patient reached the pre-
determined short-term goals
and provide feedback.
Recommend 1-month recall,
emphasize frequent recall for
gingivitis

Appointment 3:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction______
Update medical dental LTG: continue proper home Begin patient education
history, take intra oral care indefinitely now that our session 3 by reviewing
pictures, take plaque and
bleeding score, ensure
comfort of patient, patient
education session 3, check
restoration development,
cleaning, ask patient about
new baby
problems have been
addressed and completed
STG 1: continue to come to
regularly scheduled recall
appointments every 6
months
STG 2: educate patient on
use of floss threaders to
make it easier to reach the
areas where patient has a
retainer
previous sessions and
reviewing skills learned.
Report plaque and bleeding
score that was taken and
compare to past scores.
Encourage the patient that
they are doing good if the
score is decreasing. Review
goals from session 2 and
determine if they have
reached these goals. Provide
positive feedback. Proceed
into patient ed session 3 by
explaining interdental
implementation and how this
would benefit her and also
discuss child dental care.
Show the patient her probing
chart, radiographs, bleeding
and plaque score to show her
how far along she has come.
Introduce the floss threaders
and show on a typodont,
then have the patient
demonstrate the abilities
they have learned. Allow
patient to answer open
ended questions to assess er
understanding. Disclose
patient and ask her to
remove plaque areas with
the floss threader. Redisclose
and ask patient to see if she
was able to remove all of the
plaque. Compliment the
patient and provide positive
reinforcement. Return to the
patient ed table review the
session asking open ended
questions. Determine if
patient reached the pre-
determined short-term goals.
Recommend 6 month recall
and return to dental chair for
 treatment

9. Prognosis: (Is the prognosis good, fair, poor, questionable, or hopeless……base and
support your answer on age, number of teeth, systemic/social background, malocclusion,
periodontal examination, recall availability)
Prognosis for Candice is good. She is a 25 year old mom that cares about her teeth and wants to
take care of them. She had to have teeth removed for braces but After her braces were taken
off she wasn’t taught the proper way to floss therefore fell short on flossing. Bcause she found
it too difficult. Now she wants what’s best for herself and her baby.
10. Supportive Therapy: State the suggestions made to patient regarding re-evaluation,
referral, and recall schedule. (Note: Include date of recall appointment below.)
I suggested her coming in every 2-4 weeks to check on the progression of her gingivitis and her
recall appointment for cleaning and flourished application. Also, to check if the short-term and
long-term goals were met.
First appointment was 11/26/20
She came in right before Christmas on 12/15/20
1/5/21
After these dates it goes back to 6month recall appointment if nothing changes. No referrals
have been made. 6/1/21