DHYG 1311 APPENDIX

PERIODONTAL CARE PLAN (PCP)

TEMPLATE

Use this template to write your care plan and submit through Blackboard. You will need to expand
this.
Care Plan Part 1 submission will include Template items #1-8, using findings from initial patient
appointment.

Care Plan Part 2 submission will include entire PCP Template with all items completed.

Patient Name - Age - 58

Date of initial exam - 1 -27-2022 Date completed – 3-8-22

1. Medical History: (systemic conditions, pre-medication, medical clearance, medications, etc.) Explain
steps to be taken to minimize or avoid occurrence. Discuss in detail the relationship and effects of
medical findings on patient periodontal diagnosis, progression, and treatment.

Patient is 58 years old; height of 5’0’’ weighing 172 pounds and of Caucasian descent. Last physical took
place in February of 2019 with her primary physician Oscar Enriquez located in Port Arthur, TX. The
patient is under the care of the same physician for her medical issues and medications. Patient presents
with high blood pressure, type 2 diabetes, fibromyalgia, GERD, hypothyroidism, severe headaches, and
seasonal sinus issues. Patient is currently taking Benazepril for her stage 2 hypertension; on 1-27-22 her
blood pressure was 142/83 taken on her right arm was indicative of stage 2 hypertension. High blood
pressure can cause gingival enlargement and affect the effectiveness of anesthesia. With gingival
enlargement the patient can have increased plaque retention. At every appointment monitor vitals and
watch for any extreme elevation or decrease in BP, sit patient in a semi supine position while cleaning
and allow the patient time to adjust after sitting them upright to avoid syncope. For type 2 diabetes she
is taking metformin. On 1-27-22 blood glucose was 204 with an A1C of 6.1 in November of 2021.
Diabetes increases her risk of periodontal disease, increases her healing time and reduces her ability to
fight infection, thus reduction in her host ability to fight plaque bacteria due to higher levels of glucose
in the mouth. Monitor blood glucose levels at every appointment, making sure to watch for extreme
highs and lows, making sure to avoid hypoglycemia which can cause unconsciousness. Treat with
glucose in crash cart supplies. If glucose is too high treatment may have to be rescheduled once levels
return to a normal level; avoidance of ketoacidosis is vital. Diabetic ketoacidosis is a
serious complication of diabetes that occurs when your body produces high levels of blood acids called
ketones. The condition develops when your body can't produce enough insulin. Patient is taking
levothyroxine for hypothyroidism; common oral findings in hypothyroidism include the characteristic
macroglossia, dysgeusia, delayed eruption, poor periodontal health, altered tooth morphology and
delayed wound healing. Our patient presents with poor periodontal health and possible delayed wound
healing. Patient is currently taking glipizide for infection control. Medications used by people with
diabetes such as Glipizide and Metformin may cause changes to the oral cavity, such as candidiasis,
burning mouth, xerostomia, and the chance of getting periodontal disease and caries. Patient’s GERD,
fibromyalgia and sinus problems are not being treated with medications. GERD can cause
gastroesophageal complications and possible cancer, even enamel erosion if severe and untreated. Her
pulse was 70. +2, regular, and within normal limits. Patient’s respirations were 12, easy, regular, normal
and within normal limits. Patient’s temperature was 97.6. The patient does not need medical clearance
or premedication prior to treatment. Patient does not have any known allergies at this time. I explained
1
DHYG 1311 APPENDIX

to the patient the need for maintain her glucose levels and frequent recall to lower her plaque levels
and assist in the halting of periodontal disease.

3-8-22 at the end of treatment patient had a BP of 142/80 taken on her right arm indicating stage 2
hypertension, a pulse of 80, +2, regular, and WNL. Respiration rate was 14, easy, regular, normal and
WNL with a body temperature of 97.9. there have been no changes to her medication or overall health
history.

2. Dental History: (past dental disease, response to treatment, attitudes, dental I.Q., chief complaint,
present oral hygiene habits, etc.) Discuss in detail the relationship and effects of findings on patient
periodontal diagnosis, progression, and treatment.

Chief complaint is the need of a dental cleaning as patient is embarrassed of her smile. Her last dental
cleaning was 2-13-2020 at the LIT Dental Hygiene clinic prior to 1-27-22, where she came in for a new
cleaning. Patient’s last dental radiographs were taken on February of 2018 in the form of bitewings.
Therefore, we took new panographic bitewings and a traditional panographic to update her records to
compare bone loss and progression of disease. Patient does not maintain a proper 3 – 4-month recall
schedule to treat her periodontal disease. Patient states she understands she needs to be more
compliant with her frequent recall schedule but often forgets. Her home care routine consists of an
electric brush using the scrub method. Brushing her teeth typically once a day with occasional twice a
day. She rarely flosses and does not use a mouth rinse. Her plaque score was 3 being poor plaque
control. Upon a full mouth probe revealed a bleeding score of 10%. Patient has a very low dental I.Q. on
the importance of daily brushing, flossing and use of a fluoride rinse. I explained to the patient the need
to brush consistently twice a day and to make sure to get all surfaces of her teeth, noting the great
amount of retention around all gingival surfaces of her teeth. Patient is also unaware of how diabetes
and hypertension contribute to the severity of her periodontal disease and contributes to the delayed
healing process and ability to fight infection from the plaque bacteria. If patient is unable to modify her
home care routine and maintain her frequent recall schedule her periodontal disease will continue to
progress and lead to further bone loss and eventual tooth loss. In addition, periodontal disease will
contribute to her overall health decline, it can increase the severity of her hypertension, diabetes and
her hypothyroidism. Patient states she clenches her jaws due to stress and has dry mouth due to her
medications. I explained to her the need to use saliva substitutes and take frequent sips of water to
assist in this matter. Also explained the importance of maintaining frequent recall appointments to
reduce the severity of periodontitis in an attempt to halt the progression all together. Patient states she
consumes less than 2 sugary drinks a week.

3-8-22 the patient’s plaque score was again a 3 with a poor evaluation indicative that the patient is not
following the home care routine suggested for her plaque reduction. Patient’s dental IQ is still very low
in her understanding of the periodontal progression. Patient states she is now using a mouth rinse with
fluoride and attempting to brush 2 times daily, but still in using a scrub method in a very scattered
technique. No gingival bleeding with limited teeth selected. Most likely due to poor gingival health
lacking proper circulation. In the 6 weeks since treatment began patients oral health has not improved.
During this visit we held a patient education session to increase her knowledge of plaque and how her
diabetes directly contributes to her periodontal disease. Discussed further in appointment 3.

3. Oral Examination: (lesions noted, facial form, habits and awareness, consultation, etc.) Discuss in
detail the relationship and effects of findings on patient periodontal diagnosis, progression, and
treatment.
2
DHYG 1311 APPENDIX

During her intra oral and extra oral examination there was nothing found to be abnormal or of current
need for a referral to a specialist for further examination or inspection. Patient’s occlusion was a class 1
on the molar and canine of her right side, with a molar tendency to a 2 on her left and a class 3 on her
left canine. Patient has an overbite of 2 mm, an overjet of 2mm and no midline shift. Open bite on #7, 8,
9, 10, 23, 24, 25, 26. And an end-to-end bite of 11 and 22. Patients oral habits of mouth breathing can
increase her dry mouth, and has a tongue thrust when swallowing.

4. Periodontal Examination: (color, contour, texture, consistency, etc.) Discuss in detail the relationship
and effects of findings on patient periodontal diagnosis, progression, and treatment.

Patient presents with generalized scalloped architecture, generalized red color, edematous, rolled and
bulbous gingiva, without suppuration, with smooth and shiny papillary and marginal texture and
generalized stippled attached gingiva.

There were no changes to the patient’s gingival description. It appears she has not changed and home
care therefore, her oral health has not improved either.
a. Periodontitis Stage: 2 Periodontitis Grade: B Extent & Distribution: generalized papillary and
marginal

Describe determining factors/ etiology behind Stage AND Grade:

Periodontal assessment revealed patient has several places of recession with most have a CAL of 3 mm
or 4 mm but one localized spot of 6 mm, and gingival inflammation causing the other places to have CAL
of 1 mm and 2 mm. Patient also has radiographic bone loss generalized in all posterior regions,
maxillary and mandibular for less than 15% and 15% - 33% bone loss generalized on her anterior
maxillary and mandibular. Patient has had tooth # 1, # 2 and #5, #16, #17 extracted most likely due to
decay. All findings leading to a diagnosis of periodontal stage 2 and grade B. low socioeconomic
standing along with low dental IQ has greatly contributed to her periodontal disease, only to be
exacerbated by her diabetes, hypothyroidism and hypertension.

b. Gingival Description: (describe by quadrant at each appointment)

Appointment 1 (initial): Patient presents with generalized scalloped architecture, generalized red color,
edematous, rolled and bulbous gingiva, without suppuration, with smooth and shiny papillary and
marginal texture and generalized stippled attached gingiva.

Appointment 2: Patient presents with generalized scalloped architecture, generalized red color,
edematous, rolled and bulbous gingiva, without suppuration, with smooth and shiny papillary and
marginal texture and generalized stippled attached gingiva. No visible changes to the gingiva.

Appointment 3: Patient presents with generalized scalloped architecture, generalized red color,
edematous, rolled and bulbous gingiva, without suppuration, with smooth and shiny papillary and
marginal texture and generalized stippled attached gingiva.

Appointment 4:

Appointment 5:
3
DHYG 1311 APPENDIX

Appointment 6:

c. Plaque Index: Appointment 1- 3 (poor), 2- 2.3 (poor), 3- 3 (poor), 4_____ 5_____ 6_____

d. Gingival Index: Initial 1.17 Final 1.04

e. Bleeding Index: Appointment 10% 2 0% 3 0% 4_____ 5_____ 6_____

On 3-8-22 upon a full mouth probe the patient had a bleeding score of 11% when the initial bleeding
score did not show this.

f. Evaluation of all index findings. Discuss in detail the relationship and effects of findings on
patient periodontal diagnosis, progression, and treatment. (Do this for initial and final appts and
compare progress at final appt).

1. Initial appointment (baseline): Patient has moderate periodontal disease with

bleeding. Patient has 6 extracted teeth, with 10 restorations. Generalized pockets depths of 3
mm and 4 mm pockets with a CAL of 6 at the greatest point. Patient has generalized recession
on the buccal and facial surfaces.
Patient’s general lack of knowledge is contributing greatly to her condition. She has
multiple systemic medical conditions that not only increase her risk but also contribute to her
inability to control the disease. With chairside education it is possible for her to increase
awareness and knowledge to reduce her plaque and bleeding scores to assist in halting the
progression.

2. Final appointment (re-evaluation): Patient has moderate periodontal disease with

bleeding. Patient has 6 extracted teeth, with 10 restorations. Generalized pockets depths of 3
mm and 4 mm pockets with a CAL of 6 at the greatest point. Patient has generalized recession
on the buccal and facial surfaces.
Patient has not altered her home care routine except the purchase of ACT mouth rinse
to add into her routine. It appears she has not modified her home care and her prognosis is
poor. She seems settled into her routine and lacks the desire to change. Unfortunately, this will
most likely contribute to tooth loss in the future.

g. Periodontal Chart: (pocket depths, recession, CAL, furcation, mobility, etc.) Discuss in detail the
relationship and effects of findings on patient periodontal diagnosis, progression, and treatment.
Compare progress at final appt.

1. Initial appointment (baseline):

Maxillary right: Tooth # 1, 2, and 5 are missing most likely due to decay, 2 mm recession
on # 7, CALs of 1 to 3 and pockets depths mostly 3 mm, localized 4 mm pocket in the
interproximal of # 3 and 4.
Maxillary left: tooth # 16 extracted likely due to decay. 2 mm recession on the facial
surface of tooth # 10,1 4, and 15, pocket depths of 2 mm and 3 mm with a localized pocket of 4
mm on the mesial of # 15. CALs ranging from 0 to 4 mm.
Mandibular left: tooth # 17 extracted likely due to decay, 1 mm recession on # 19, 20,
22, and 24, 3 mm recession on # 21, CALs ranging from 0 to 4, generalized pocket depths of 3
and 4 mm.
4
DHYG 1311 APPENDIX

Mandibular Right: 2 mm recession on tooth # 28, 30, and 1 mm recession on tooth # 29,
CALs generalized at a 1, with localized 6 mm on tooth # 28
Patient has several areas of recession causing exposed root surfaces. This can easily lead
to root caries and sensitivity. Deep periodontal pockets allow bacteria retention and only
contributes to the progression of periodontal disease. The patient already has 10 restorations
indicating she is already a caries risk.
The patient is unaware of the severity of her periodontal disease and is unaware of how
her hypertension, diabetes, and hypothyroidism are contributing to the disease. Patient does
not have a good home care routine and typically only brushes once a day if at all. Patient does
not floss or use mouth wash. Prognosis is poor if routine does not change.

2. Final appointment (re-evaluation):

Maxillary right: Tooth # 1, 2, and 5 are missing most likely due to decay, 2 mm recession
on # 7, CALs of 1 to 3 and pockets depths mostly 3 mm, localized 4 mm pocket in the
interproximal of # 3 and 4.
Maxillary left: tooth # 16 extracted likely due to decay. 2 mm recession on the facial
surface of tooth # 10,1 4, and 15, pocket depths of 2 mm and 3 mm with a localized pocket of 4
mm on the mesial of # 15. CALs ranging from 0 to 4 mm.
Mandibular left: tooth # 17 extracted likely due to decay, 1 mm recession on # 19, 20,
22, and 24, 3 mm recession on # 21, CALs ranging from 0 to 4, generalized pocket depths of 3
and 4 mm.
Mandibular Right: 2 mm recession on tooth # 28, 30, and 1 mm recession on tooth # 29,
CALs generalized at a 1, with localized 6 mm on tooth # 28
Patient’s overall periodontal status has had little to no change. Patient seems to not
follow through with her home care properly. Periodontal disease is unlikely to change if patient
in unable to alter her home care habits.
Patient was educated in a modified patient education session on plaque and brushing.
Patient was shown how to use the Bass method on a typodont, as well as demonstrated how to
do so. Once patient practiced in mirror, she had difficulty brushing teeth. It is possible the
patient was suffering from anxiety, but patient also mentioned she was sleep deprived from the
night before. Prognosis is poor as her plaque score did not change from the initial visit to the
last, her home care did not change, her ability to retain the chairside information weas poor and
her overall health as stayed the same if not declined somewhat.

5. Dental Examination: (caries, attrition, midline position, mal-positioned teeth, occlusion, abfraction,
missing teeth, etc.) Discuss in detail the relationship and effects of findings on patient periodontal
diagnosis, progression, and treatment.

Patient has no referrals for new decay, but has 10 previous restorations, 6 missing teeth, generalized
recession on the buccal and facial surfaces, an open bite on the right side, her occlusion on the right is a
class 1 but the left is a molar tendency to 2 and a canine tendency to 3. Her occlusion does not
contribute to her periodontal disease. Her recession, and restorations can harbor bacteria and then
contribute to the decline of her gingival health.

6. Radiographic Findings: (bone loss, furcation, crown root ratio, root form, condition of interproximal
bony crests, thickened lamina dura, calculus, root resorption, missing teeth, etc.) Discuss in detail the
relationship and effects of findings on patient periodontal diagnosis, progression, and treatment.
5
DHYG 1311 APPENDIX

Patient has generalized bone loss in the anterior maxillary and mandibular of 15% - 33% and generalized
posterior maxillary and mandibular bone loss of 15%. Calculus visible on the maxillary left quadrant. 3
missing teeth in the maxillary right quadrant, 1 missing tooth in both the maxillary and mandibular left
quadrants. The generalized bone loss shows areas where retained bacteria has eroded the bone away
causing deeper pockets and increased CAL measurements. The retained calculous shows an area where
the patient routinely does not remove the bacteria when brushing.

7. Periodontal Disease Risk Factors: (include positive findings noted on the Periodontal Risk
Assessment) Discuss in detail the relationship and effects of findings on patient periodontal diagnosis,
progression, and treatment.

Patient is over the age of 55 increasing her need for frequent recall due to an increased risk of class 5
carries, has a decreased saliva and should use a saliva substitute and/or xylitol products to combat the
symptoms has poor plaque control due to lack of pro[per home care, patient was shown how to use the
Bass method for brushing and was sent a video tutorial to follow at home, radiographic bone loss also
indicated the need for frequent recall, CAL has a need for proper home care and well as the need to
maintain recall. Patient has diabetes, hypertension, hypothyroidism and all of these conditions have a
need for proper home care and frequent recall but more importantly she needs to control her blood
glucose levels to reduce the levels in her mouth that are feeding the bacteria. Inflammation is present
throughout her mouth indicating a need to brush and floss daily, her medications cause xerostomia, and
she was informed that she need to incorporate a xylitol mouth rinse into her daily routine and take
frequent sips of water. Demineralized areas again call for frequent recall, her infrequent dental visits are
causing the bacteria to buildup, she has more than 5 prior restoration and needs to maintain a recall
schedule. Her exposed root surfaces indicate the need for fluoride varnish and fluoride rinse at home.

8. Treatment Plan: (Include assessment of patient needs, appropriate treatment, patient education
plan- including individualized long and short-term goals)
Appointment 1: Patient indicates her chief complaint of needing a cleaning. Therefore, the following
assessments were performed to gather data: Covid screen, payment collected, hipaa, private practice,
statement of release, medical/dental history reviewed, vital taken, pre-rinse, BWX and Pano performed
to check bone levels and for decay, head and neck exam, intra/extra oral exam, dental charting with x-
rays, periodontal assessment, gingival assessment, occlusion classification, plaque and bleeding score
taken. Once all information gather was complete some chairside education on plaque and brushing was
done. A risk assessment was performed, and an informed consent was signed. Patient was classed at a
class 3 prophy and a class 2 stage B periodontal disease. Set patient up for root debridement plan and
scheduled her recall appointments. Patient has a TTM of contemplation.

Appointment 2: covid screen, pre-rinse, medical/dental history reviewed, vital taken, plaque score,
bleeding score, ultrasonic and fine scaled maxillary and mandibular right, chairside patient education on
the importance of brushing daily, flossing, and the use of fluoride products to assist with caries
prevention on her areas of recession, scheduled next appointment. Patient has a TTM of
precontemplation.

Appointment 3: covid screen, medical/dental history reviewed, vitals taken, plaque score, bleeding
score, ultrasonic and fine scales maxillary and mandibular left, modified patient education session to
discuss what plaque is, how the Bass method of brushing is essential to the removal of plaque, have
patient demonstrate on typodont and self, educate patient on how her diabetes is contributing to the
6
DHYG 1311 APPENDIX

severity of her periodontal disease and how plaque removal will reduce her progression. Have patient
explain to me what she learned and can recall from the session. Gave patient a list of her goals.
Long term goal: halt the progression of periodontitis be reducing bleeding score to a zero by next recall
appointment.
Short term goal: understand what plaque is and how to use the Bass method
Short term goal: reduce bleeding score by 1 point by next appointment
Short term goal: understand the role diabetes plays in periodontitis, maintain blood glucose levels to
assist in halting progression of periodontitis.
Showed patient her radiographs to make the diagnosis and treatment plan more relatable. Reviewed
her goals, gave her a handout of goals, brushing method directions with images, flossing method
directions with images. Ultrasonic and fine scaled maxillary and mandibular right, plaque free, 5% NaF
varnish. Scheduled her recall appointment.

Appointment 4:

Appointment 5:

Appointment 6:

9. Journal Notes: (Record in detail the treatment provided at each appointment, oral hygiene
education, patient response, complications, improvements, diet recommendations, learning level,
progress towards short and long-term goals, expectations, etc.) The notes should be written by
appointment date.
1-27-22: Covid screen, payment collected, hipaa, private practice, statement of release, medical/dental
history reviewed, vital taken, pre-rinse, BWX and Pano performed to check bone levels and for
decay, head and neck exam, intra/extra oral exam, dental charting with x-rays, periodontal
assessment, gingival assessment, occlusion classification, plaque and bleeding score taken.
Patient explains her blood glucose was a little high due to her breakfast, she had taken her medication
and thought her glucose levels would lower soon, her A1C was 6.1 in November. Once the data
collection was complete and I was covering her plaque score and how proper brushing was essential
twice a day she explains she doesn’t want to use fluoride products because she is trying to be all
natural. I provided her with a fluoride benefits sheet and explained to her the value of fluoride and
how it is naturally occurring element in our planet and safe for use. She seemed receptive and said
she will try to brush twice a day.
2-1-22: covid screen, pre-rinse, medical/dental history reviewed, vital taken, plaque score, bleeding
score, ultrasonic and fine scaled maxillary and mandibular right, chairside patient education on the
importance of brushing daily, flossing, and the use of fluoride products to assist with caries
prevention on her areas of recession.
Patient says she bought ACT mouth rinse with xylitol to help with her dry mouth and is trying to brush
twice a day and decided to use products with fluoride. Again, I stressed the importance of brushing
twice a day and incorporating flossing into her routine. She does not seem to be following through
with home care, since her gingival appearance has not changed, and the plaque score was relatively
the same.
3-2-22: covid screen, medical/dental history reviewed, vitals taken, plaque score, bleeding score,
ultrasonic and fine scales maxillary and mandibular left, modified patient education session,
ultrasonic and fine scaled maxillary and mandibular right, plaque free, 5% NaF varnish. As well as
went back over the previously scaled areas to confirm all calculous was removed.
Patient was receptive but had a very strange manner about herself this appointment. Says she slept very
7
DHYG 1311 APPENDIX

little the previous night and had not had breakfast. During the patient ed session she seemed to
have trouble holding the brush, following directions, and did not have a lot to say. She seemed to
comply and want to understand her needs but was not all there. I sent her home with the handouts
for reference, and she was happy to have them. I am not sure patient will follow through with
proper home care.

10. Prognosis: (Based on attitude, age, number of teeth, systemic/ social background, malocclusion,
tooth morphology, periodontal examination, recall availability)
Prognosis is poor for this patient. She did not seem to fully grasp how important home care is. She has a
poor diet of mainly fast food, that her husband gathers for her. She lacks self-discipline to change
her daily routine and lacks dental IQ to know the importance of what I was trying to explain to her.
At 58 she is well set in her ways and is already hardwired for oral health laziness. Patient already has
10 restorations and missing teeth with no real desire to change anything about her health. She has
other ongoing medical issues making it more complicated and distracting the patient from making
the changes needed to halt the progression of the disease. She does not have dental insurance and
lives on her husband’s disability income. She is a reliable patient and if scheduled she will maintain
her recall appointments, so if a student can maintain her on future schedules, it can at least help a
little.

11. Supportive Therapy: Suggestions to patient regarding re-evaluation, referral, and recall schedule.
(Note: Include date of recall appointment below.)
Patient is scheduled for 3 month recall and she has been made aware of the importance of maintaining
her 3 month recall schedule. She knows she should be contacted next semester by a student and if
scheduled accordingly she can come 4 times a year to our clinic. No referrals. Her recall date is April
2022 for a post perio evaluation. Then her recall will be July 2022.

12. Assessment of Changes: (note “Periodontal Grade” at the end of treatment, compare changes in
periodontitis classification, changes in plaque control, bleeding tendency, gingival health, probing
depths, effect on future periodontal disease management)
The patient had little to no changes to her gingival health or her perio stage and grade. It is likely due to
her lack of proper home care, exacerbated by hypertension, diabetes and hypothyroidism. Her plaque
score stayed the same throughout treatment at a 3 (poor) and her bleeding score only reduced due to
only using select teeth. Once a full mouth probe was completed again it actually increased from 10% to
11%. Again, indicating lack of proper home care. Her gingival health is still rather poor with generalized
scalloped architecture, generalized red color, edematous, rolled and bulbous gingiva, without
suppuration, with smooth and shiny papillary and marginal texture and generalized stippled attached
gingiva. Patient began treatment with stage 2 grade B periodontitis and ended with the same.

13. Patient Attitudes and Cooperation:

Patient does state she wants to do better but her gingiva shows she has not taken the steps to improve
her home care routine. She does show up to her appointments which is promising. Hopefully with
continued patient education her home care routine will improve.

14. Personal evaluation/ educational progression with this experience:

It was very challenging to educate a patient who appeared to not care too much about what you had to
say. I know this will continue to occur in my career. It was strange to watch a grown woman struggle
with brushing her teeth. I am not sure if it was exhaustion or just her mental awareness. But this was a

8
DHYG 1311 APPENDIX

reminder on how to adjust your education methods to the patient and not always repeat the same
information to all people. Not all people with learning challenges present the same in all people.