DENTAL HYGIENE CARE PLAN TEMPLATE

Care Plan submission will use findings from included patient information.
Student Name: Carolina Sifuentes
Patient Name: Rona Williams Age: 53
Chief Complaint: Tender gums
1. Medical History: (list any positive medical history findings from the medical & social history.
Correlate what the positive findings place the patient at risk for.)
Medical History Findings At Risk For: ______________

Patient has had no physical since 2019. Undiagnosed disease/condition such as

Hyperthyroidism or Graves’ disease.

Takes Prescription medication for seizures- Oral side effects: swelling/bleeding on gums,
Phenytoin. vomiting, xerostomia.

Patient was hospitalized for having a broken Could experience breathing or chest
rib in 2020. problems during dental procedure.

Under the care of a physician for seizures. Could lead to broken teeth from potential
fall. And the broken teeth can lead to tooth
infection.

Highly active, works part time, full-time Neglecting home care instructions: brushing,
mother, and housekeeper. flossing, and rinsing.

2. Dental History: (List past and/or present dental disease, the chief complaint, and the present
oral hygiene habits. Correlate what the findings place the patient at risk for.)
Dental History Findings At Risk For:_____________

No dental visit in the past two years. Plaque and calculus accumulation, gingival
bleeding, sensitivity, & periodontal disease
progression.

Experiences bleeding and tender gums. Developing gingivitis or periodontitis.

Pt. has one broken tooth. Developing dental infection or cavity.

 Only brushes once a day and rarely flosses. Increase in plaque buildup that can lead to
developing caries, gingivitis, or periodontitis.

Teeth shifting Malpositioned teeth with malocclusion which

can make it difficult to properly brush in
between teeth and can lead to plaque
buildup and tooth decay.

3. Extraoral & Intraoral Examinations: (List the positive findings, habits and awareness.
Correlate what the findings place the patient at risk for.)
Extra & Intraoral Examination Findings At Risk For:___________

Large thyroid gland Undiagnosed disease/condition such as

Bilateral popping and clicking of the TMJ
hyperthyroidism or graves’ disease. Which
could cause xerostomia, also at risk of mouth
& tooth infections, and increased cavity
development.
Dysfunction of the TMJ. Can lead to tooth
loss and gingival recession.

4. Periodontal Examination: (Describe the gingival color, contour, texture, and consistency. List
general biofilm locations, biofilm retentive features, predisposing factors to biofilm retention,
pocket depths, CAL, bone loss, make reference to location of bleeding sites, etc. Determine
periodontal diagnosis. Correlate what the findings place the patient at risk for.)
Periodontal Assessment Findings At Risk For:_______________

Pt. has generalized red, rolled, edematous Progressing to severe periodontitis with
gingival tissue. Has generalized moderate potential for additional tooth loss at a rapid
biofilm with biofilm retentive features that rate of progression.
include calculus, periodontal pockets, decay,
and malpositioned teeth with malocclusion.
Predisposing factors include phenytoin
medication. Has generalized 4mm pocket
depths, with generalized bleeding, class 4
calculus, localized CAL with 2mm facial
recession on #24 and #25 and generalized
slight horizontal bone loss (<15%).
 Periodontal Diagnosis: Generalized moderate
periodontitis with localized CAL and localized
gingival recession. At a moderate rate of
progression.

a. Periodontitis Stage: ll Periodontitis Grade: B

b. Plaque Score: 2 Evaluation of plaque score: Fair
c. Bleeding Score: 65%
5. Dental Charting Examination: (List all findings from dental charting exam. Examples are
caries, attrition, midline position, occlusion, abfractions, etc. Correlate what the findings place
the patient at risk for.)
Dental Charting Findings: At Risk For:___________________

Malocclusion-class 1 Difficulty taking care of, can lead to tooth

decay or tooth loss.

Amalgam restorations Recurrent decay/ defective restoration.

Broken tooth: #3 Developing infection/cavity.

Pt. is missing teeth: #1, #7, #10, #16, #17, #32 Disease progression, shifting, supra-
eruption, & malpositioned teeth, food
impaction.

6. Radiographic Findings: (List the conditions such as crown to root ratio, bone loss, condition
of interproximal bony crests, thickened lamina dura, calculus, decay, root resorption, etc.
Correlate what the findings place the patient at risk for.)
Radiographic Findings:___________________________At Risk For:_________________

Generalized slight horizontal bone loss <15% Perio disease progression, tooth loss,
mobility.

#3 broken tooth with radiographic decay. Pain, increased plaque retention, decay
progression.

Localized facial recession on tooth #24 and Exposed root surfaces with sensitivity.
#25
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:_________________

Moderate periodontitis Plaque biofilm & host response, infrequent

dental care, risk factors

Tooth Decay Inadequate homecare, bacteria.

Gingival inflammation & bleeding Plaque biofilm, biofilm retentive features,

inadequate homecare.

Moderate supragingival and subgingival Inadequate homecare, infrequent dental

calculus deposits. (Class 4) care.

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 3 short-term goals.
Appointment 1: (Initial Appointment- patient assessment & data collection)
Completed: Home Care evaluation:
Medical and Dental history Patient uses horizontal brushing method,
Extraoral/intraoral examination brushes once a day with toothpaste for
Periodontal assessment examination sensitive teeth, and rarely flosses.
Dental charting examination
Periodontal charting
Radiographic findings
Plaque score and bleeding score
Assessment of patient homecare and habits

Appointment 2:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
Supra- and subgingival  LTG #1: Patient will decrease  Explain importance
scale and root plaque score by 75% by of homecare
debridement max 02/01/22. instructions
right quad, patient ed. compliance and that
success of treatment
depends on
thorough, daily
 biofilm removal.

 STG: Patient will decrease  Explain plaque

plaque score by 25% or retentive features.
more at each visit.

 STG: Patient will understand  Explain plaque

what plaque is and be able theory, ask open-
to define plaque by ended questions,
11/15/21. explain how
medications can
affect oral health.

 STG: Demonstrate proper  Recommend more

brushing technique by frequent plaque
11/15/21. removal.

Appointment 3:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
Supra- and subgingival  LTG #2: Patient will halt  Explain perio disease
scale and root periodontal disease progression process, use patient’s
debridement on max and prevent recurrence by x rays to show bone
left quad and mand reducing/maintaining bleeding loss. Recommend 3-
left quad, patient ed. score to 0% by 02/01/2022. month recall,
emphasize, and
encourage frequent
recall for perio and
regular scheduled
maintenance follow-
up for dental hygiene
care. Recommend a
consult with
Periodontist.
 STG: Patient will understand
what periodontitis is and the  Explain what
cause of periodontitis by periodontitis is and
11/29/21. the cause of
periodontitis, ask
open-ended
questions, explain
how medications can
 STG: Reduce bleeding score
 by 22% at each appt. lead to oral disease.

 Use patient’s probe

chart to show pocket
depths and bleeding
points. Explain
 STG: Patient will
importance of
demonstrate proper flossing reducing bleeding
technique and start flossing points.
once a day by 11/29/2021.  Educate on
importance of
flossing once a day.
Appointment 4:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
Supra- and subgingival  LTG #3: Patient will get broken  Recommend use of
scale and root tooth with decay restored by mouthguard, use
debridement on mand 02/01/2022. patients x rays to
right quad, patient ed. show radiographic
decay.

 STG: Patient will understand  Explain what caries is

the cause of caries and and the relation to
relation to the diet by end of the diet, ask open-
this appt. ended questions.

 STG: Patient makes an  Emphasize

appointment with DDS for importance of
tooth restoration and for restoration.
possible replacement of
missing teeth by
12/13/2021.

 STG: Patient will understand  Explain how they

how seizures can lead to oral could fall and hit
issues by end of this appt. their head or break
their teeth and how
seizure medication
can lead to more
caries.
Appointment 5: (if needed)
Plan for Treatment: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________

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)

Fair- Pt. has a fair potential to meet expected outcomes due to being 53 years old, having
twenty-six teeth, has a chronic systemic disease, active social background, has less than 25%
attachment loss, has moderate periodontitis, has adequate self-care ability & control of
etiologic factors, and expects to be available for her recall appointments.

10. Supportive Therapy: State the suggestions made to patient regarding re-evaluation,
referral, and recall schedule. (Note: Include date of recall appointment below.)

Patient needs re-evaluation of periodontitis disease and overall response to treatment in 3

months on 02/01/22. If resolution does not occur, periodontal surgery or antiseptic
mouthwash will be considered.
Patient was referred to DDS for broken tooth with decay by 12/13/21.
Recall schedule: 2nd appointment- 11/8/21
3rd appointment- 11/15/21
4th appointment- 11/29/21
Re-evaluation appointment- 02/01/22