CARE PLAN TEMPLATE

Care Plan submission will use findings from included patient information.
Student Name _Haleigh Fritzenschaft____________________________________________
Patient Name_Karla Banks___________________________________________Age___43____
Chief Complaint: _bad breath and stained teeth ______________________________________
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:______________
-Smoker (26 years), smokes a pack of
cigarettes/day (20/day) Risks from smoking and drinking:

-Socially drinks alcohol on weekends
-eats mostly fast food on the run
-Rheumatoid arthritis (diagnosed recently)
-Medications: methotrexate (for Rheumatoid
arthritis)
Oral cancer, leukoplakia, tooth loss, staining,
periodontitis, gingival bleeding, calculus, dental
caries, smoker’s palate, hairy tongue, leukoedema,
median rhomboid glossitis, oral clefts, lichen planus
Side effects from Methotrexate:
Mouth sores, reduced number of white blood cells,
nausea, stomach pain, tiredness, chills, fever,
dizziness

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:_____________
-no dental exam nor cleaning in 10 years
Dental caries, interproximal caries,
-brushes daily with powered toothbrush gingivitis, staining, tooth decay, high
-doesn’t floss bacteria count, calculus, build up,
increase in periodontal disease
-consumes sugary mints throughout the day to help
with bad breath
Chief Complaint: staining on teeth and bad breath
3. Oral Examination: (List the positive findings, habits and awareness. Correlate the effects on
periodontal diagnosis)
Oral Examination Findings At Risk For:___________
-generalized slight nicotine stomatitis
Cancerous mucosal change of the
-generalized moderate to heavy brown stain hard palate, hairy tongue, higher
caries rate, periodontitis, xerostomia,
decreased salivary production
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.)

-generalized severe gingival enlargement, fibrotic, whitened marginal, papillary redness with
rolled margins, stippled attached gingiva
-generalized maxillary and mandibular probing depths of 5-6mm with localized bleeding
-generalized moderate subgingival calculus and moderate stained biofilm (class IV)
a. Periodontitis Stage: _II___ Periodontitis Grade: __C__
b. Plaque Score: _3.7 (74%)______ Evaluation of plaque score: __poor_______
c. Bleeding Score: __16%____ Evaluation of bleeding score: ___good________

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 occlusion right/left, with slight mandibular
anterior crowding Dental caries, interproximal caries,
and reoccurring caries, defective
-#3 MO broken tcr restorations
-#5 MOD broken tcr
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:_________________
-tcr: #3 MO; #5 MOD (both broken restorations)
Dental caries, recurrent caries,
-generalized 15-30% horizontal bone loss subgingival calculus, high count of
-missing teeth: #1, #16, #17, #19, #32 bacteria/plaque, movement of teeth,
loss of attachment

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:_________________
1. periodontal case stage II
1. Plaque buildup, poor oral hygiene, infrequent dental visits, infrequent
– moderate bone loss flossing, disease progression
2. plaque/calculus 2. Poor brushing methods, infrequent flossing, infrequent dental visits,
uneducated about oral bacteria
3. tobacco cessation 3. Bad breath, stained teeth, hairy tongue, leukoplakia, periodontitis,
gingivitis, smoker’s palate, oral cancer, tooth decay
4. infrequent dental visits
4. Understanding the importance of frequent dental visits, especially when
at risk for oral cancer.

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
______________________________________________________Hygiene Instruction
Medical/dental hx LTG1: Karla’s chief complaint Patient Ed:
Intraoral/Extraoral exam is her stained teeth & bad -go over chief complaint with
Dental Charting breath. Her long term goal Karla & help Karla understand
Periodontal Assessment will be to start cutting back on why her teeth are stained and
Bleeding score/plaque score a few cigarettes a day. what is causing her bad
Intraoral pictures for patient STG: encourage Karla to breath
to see attend support groups to help -discuss tobacco cessation
Patient ed. session with reduced smoking and -talk to Karla about side
Informed consent motivation to quit effects (bad breath, stained
STG: find a nicotine teeth, stress, cancer, etc.) of
 alternative (patch, nasal
spray, gum, inhaler, etc.)
STG: Karla will know how to
self examine for oral lesions
by the end of the 1st
appointment
STG: Karla will go see her
doctor to help with nicotine
cravings.
smoking by using information
& pictures from the flipbook
to help her understand
-teach Karla how to self-
examine for oral lesions at
home

Appointment 2:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction
Medical/dental hx LTG2: Karla has a plaque Patient Ed:
Plaque/bleeding score score of 3.7 and will reduce -review tobacco cessation
Patient ed session bacteria count in the mouth -ask the patient how her goals
Scale maxillary quad(s) by reaching a plaque score of towards quitting are going
3.0 or less by next -review necessary methods to
appointment. encourage patient if needed
STG: Karla will understand
what plaque is and be able to -define plaque by using
define it. She will understand flipbook
how to use disclosing solution -discuss plaque score and
to know where to bacteria teach Karla how to reduce it
build up is by her next by her next visit
appointment. -discuss how and why plaque
STG: Karla will demonstrate is harmful
proper toothbrushing
technique -go over toothbrushing with
Karla by using flipbook and
videos from computer. Karla
uses a powered toothbrush,
so she would learn that the
toothbrush does the work,
she only angles it and needs
to take her time with
brushing (2 minutes)
-have Karla demonstrate the
toothbrushing technique to
make sure she understands
Appointment 3:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction______
Medical/dental hx LTG3: Karla will stop the Patient Ed:
Bleeding/plaque score progression of her -review tobacco cessation
Patient ed session periodontal disease by -ask the patient how her goals
Scale mandibular quad(s) lowering her bleeding score towards quitting are going
to 15% by next appointment. -review necessary methods to
STG: Karla will be able to encourage patient if needed
identify, define, and
understand periodontal -review plaque and
disease/gingivitis toothbrushing with patient
STG: Karla will be able to learned from previous
demonstrate proper flossing appointment. Make
technique that she can adapt adjustments as needed
to.
STG: Karla will reduce her -discuss flossing and its
bleeding score to 15% by her importance
next appointment by flossing -demonstrate correct flossing
twice/week. technique that adapts to the
patient
-have patient demonstrate
flossing technique on
typodont for understanding

-discuss gingivitis/periodontal
disease – use flipbook to
describe and show pictures to
patient
-use radiographs to show the
bone loss in Karla’s oral
region.
-discuss how Karla can stop
the progression of her
periodontal disease

Appointment 4:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction__
 Medical/dental hx
Bleeding/plaque score
Patient ed session
Finish any patient treatment
LTG4: Karla will reduce her
risks of caries by switching
from sugary mints to sugar-
free mints.
STG: Karla will be able to
define and understand the
process of dental cavities
STG: Karla will brush and floss
more frequently to reduce
dental caries
Patient Ed:
-review tobacco cessation
-ask the patient how her goals
towards quitting smoking are
going
-review necessary methods to
encourage patient if needed
-Review definition of plaque,
toothbrushing technique,
frequency of flossing, and
gum disease. Make any
necessary adjustments

-discuss dental caries – use

flipbook to show examples to
help explain what starts caries
process

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)
Based on the Karla’s existing factors, her overall prognosis is questionable. The commitment to
quit smoking can be extremely hard due to her overwhelming and stressful job, plus the fact that
she must keep it because of her unemployment in the past. On the other hand, her chief
complaint is staining and bad breath—this might be motivation to achieving her goal. Karla also
has had unpleasant past dental visits; therefore, she might not be committed to a 3-4-month
recall. But, on the other hand, she understands the concerns for her oral health now, plus she has
insurance, so she might be committed.

10. Supportive Therapy: State the suggestions made to patient regarding re-evaluation, referral,
and recall schedule. (Note: Include date of recall appointment below.)
Referrals: broken restorations: #3 MO tcr, #5 MOD tcr; medical doctor to help with nicotine
reduction and alternatives to stress reduction
Recall interval: every 3-4 months (next recall appointment: April 27, 2020)