DENTAL HYGIENE CARE PLAN TEMPLATE

Care Plan submission will use findings from included patient information.
Student Name ___Michael Valencia _______
Patient Name ___Jennifer Cobb_____ 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: ______________

Patent is a 53-year-old female, Full-time Seizures/ epilepsy because of past seizures

mother and housekeeper, part time aide at
an elementary school and active local church
member.
Patient has been hospitalized for a broken rib
6 months ago and experiences
seizures/epilepsy. The patient is currently
under the care of a physician and takes
phenytoin.
Periodontal disease, Tooth decay, Oral
infections such as thrush may occur due to
the effects of medication patient is taking
which is phenytoin. Difficult breathing due to
broken rib.

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:_____________

Patient’s chief complaint is tender gums. Dental decay, gum disease, periodontal
Patient’s Last dental visit was two years ago, disease. Broken tooth can cause cuts or
and a tooth was pulled during the visit. infection, Tooth sensitivity may be due to
Patient has a broken tooth which is number 3 broke tooth. Due to poor brushing, patient is
but doesn’t bother patient. Patient had FMX at risk for gingivitis and caries.
in 2020 during the last dental visit. Patient
has generalized bleeding when brushing or
flossing. Teeth has been shifting for patients.
Brushes once a day and rarely flosses.
3. Extraoral & Intraoral Examinations: (List the positive findings, occlusion, midline shifts,
habits and awareness. Correlate what the findings place the patient at risk for.)
Extra & Intraoral Examination Findings At Risk For:___________

Large thyroid gland, and bilateral popping
and clicking of the TMJ.
Occlusion: class 1 right and left; molar and
canine
Large thyroid gland- Postpartum thyroiditis,
iodine deficiency, Hashimoto’s disease,
Grave’s disease, or Thyroid
TMJ disorder
Overlapping, rotated teeth, open bite or
asymmetry due to class 1 Occlusion

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:_______________

Generalized 4 mm pockets may be early or

Generalized moderate marginal redness mild periodontitis; gum disease is present
with rolled margins and edematous papilla; Sulcular inflammation due to plaque index
localized area lingual teeth # 12- 14 magenta on 4 mm pocket depths which can be an
color. Plaque found on distal and mesial of early indication of gingivitis since the gums
tooth # 3, 14, 24 on facial side. On the are magenta in color.
lingual side of 30 and 19 plaque was found 11% calculated plaque score from 26 teeth.
on the mesial, distal, and occlusal side. CAL for 24 is 3mm
Generalized 4 mm pockets on interproximal CAL for 25 is 2mm
of all molars, localized 2 mm facial recession Bleeding score is 21% and patient is at risk
#24 & 25 from radiographic findings. of periodontal disease
Generalized slight horizontal bone loss PHP score is 2
(<15%) Inflamed gumline due to plaque and
#3- broken tooth with radiographic decay bacteria causing redness rolled margins and
Generalized bleeding points on maxillary edematous
facial and lingual, mainly on the 4 mm
pocket depths. Generalized bleeding points
on facial and lingual sides of mandible on
the 4 mm pocket depths.
Generalized moderate marginal redness
 with rolled margins and edematous papilla

a. Gingivitis _____ or Periodontitis Stage: __1__ Periodontitis Grade: _A_

b. Plaque Score: __11%_____ Evaluation of plaque score: ____1_____
c. Bleeding Score: ___21%___
5. 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%) Stage 1 periodontitis

#3- broken tooth with radiographic decay Infection due to broken tooth or broken
tooth can cause a hazard to gums

6. Dental Charting Examination: (List all findings from dental charting exam. Examples are
caries, attrition, abfractions, etc. Correlate what the findings place the patient at risk for.)
Dental Charting Findings: At Risk For:___________________

Amalgam restorations generalized posterior Weakened or tooth sensitivity teeth due to

Broken tooth #3
Missing teeth: 1, 7, 10, 16, 17, and 32
restorations
Sharp fracture line from broken tooth may
cause harm In the oral cavity or infection may
occur
Missing teeth are open pockets that can be
infected by bacteria and lead to gum disease

5555555

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:_________________

Bleeding and tender gums
Broken tooth #3
Missing teeth: 1,7,10,16,17, 32
Generalized slight bone loss (<15%)
Bleeding score 21%
Plaque score 11%
Bilateral popping and clicking of the TMJ
Occlusion class 1 class right and left: molar
and canine
Generalized 4mm pockets in the
interproximal of all molars and localized 2
mm facial recession on #24 & 25
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:
Medical/ Dental history, take intraoral
pictures of patient conditions, take plaque
and bleeding score, patient education and
instruction session #2. Based on the
patient’s assessment findings and chief
complaint, First the Tender gums would
need to be assessed first. Therapy would be
needed in which deep cleaning would be
necessary for the first appointment.
Assessment findings include:
- Broken decayed tooth #3
- Missing teeth of 1,7,10,16,17,32
- Generalized horizontal bone
loss(<15%)
- Large thyroid gland
- Bilateral popping & clicking of the
TMJ
- Occlusion: class 1 right and left;
molar and canine
Bleeding and tender gums etiology-
viral/bacterial
Broken tooth etiology- trauma
Missing teeth etiology- viral or trauma
Generalized slight bone loss etiology-
viral/bacterial
Bleeding score 21% etiology – bacterial
Plaque score 11% etiology- bacterial
Bilateral popping and clicking of the TMJ
etiology- Trauma
Occlusion class 1 class right and left: molar
and canine etiology- Atypical
Generalized 4mm pockets in the
interproximal of all molars and localized 2
mm facial recession on #24 & 25 etiology-
viral/bacterial
Home Care evaluation:
Proper home care habits include:
- Brushing twice a day
- Proper brushing technique for 2
minutes
- Flossing twice a day
- Supplemental aid recommended
such as mouthwash
- Using bass brushing technique
 - Generalized moderate marginal
redness with rolled margins and
edematous papilla; localized area
lingual teeh #12-#14 magenta color
Three appointments are needed
including three separate patient Ed.
Sessions.
Patient will be informed of further
findings other than the chief
complaint once cleaning is done, as a
result patient will leave first
appointment educated and given the
goal to practice good oral hygiene
habits at home after they have been
taught how to floss and brush,
frequency of both and the proper
technique. Also, the patient will be
informed on how the medication she
Is using can be one of the factors
influencing her oral health.

Appointment 2:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
 LTG #1: (desired outcome):
patient will decrease her risk of Begin patient ed session 2 by
Check medical/ Dental further periodontal disease reviewing the previous
history for any progression by reducing her session and reviewing any
changes since last bleeding score from 21% to less previously learned skills
visit, update intraoral than 5% by the end of the final (such as toothbrushing
pictures of patient reevaluation appointment. technique). Report to the
conditions, update patient what their plaque
plaque and bleeding  STG: Patient will have a and bleeding score for that
score, follow up plaque score reduction as day are. (These will be taken
patient education and each appointment passes before the session at the
instruction session, dental chair). Review goals
Follow up short term  STG: Patient is in the early from session 1 and
goals and long term stages of periodontitis and determine if patient
goal progress. Check would need to be treated achieved those short -term
with dentist in order and educated on stopping goals. Provide positive
to get patient’s tooth the progression. Visual feedback. If patient did not
#3 pulled in order to illustrations will be used in
prevent infection. order to motivate the
patient into doing their part
at home with good hygiene
habits, patient will
understand what
periodontitis is and be able
to know what she can do to
be able to halt its
progression.
reach goals, then the dental
hygienist would need to
know why and provide
additional instructions to
further assist the patient in
achieving. Proceed into
Patient Ed session 2 by
explaining periodontal
disease & the inflammatory
process to the patient.
Review what the short term
goals will be and how they
will help the patient achieve
the desired outcome which
would be the long term goal.
Then use patient’s intraoral
pictures as visual aides to
show inflammation &
recession inside the mouth,
in which will motivate the
patient. Then use patient’s
probe chart as a visual aid to
show pocket depths of 4mm
& bleeding points. Next will
Discuss what the patient’s
own bleeding score means
related to the amount of
inflammation. Using the
patient’s x-rays as a visual
aid to show the horizontal
bone loss. Furthermore,
discussing the patient’s
stage of periodontitis which
is stage 1 grade A and a early
stage of periodontitis
progression. Discuss the risk
factors of periodontitis and
show her Risk Assessment
form as a visual aide.
Reinforce the importance of
thorough plaque removal
daily. Introduce and
demonstrate the proper
supplemental aid for
 interproximal plaque
removal such as proxy brush
or mouthwash then
demonstrate the use of the
proxy-brush on a typodont.
Allow patient to answer
open ended questions to
assess her understanding of
periodontitis and
inflammation. Using a new
brush allow patient to
demonstrate how to
properly brush and use the
bass brushing technique.
Observe and assess her
ability to properly brush.
Redisclose the patient and
ask her to look in the mirror
and see if she was able to
remove the areas of 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 4–6-month
recall, emphasize frequent
recall because of early
stages of perio. If
periodontitis gets worse
recommend a future consult
with a periodontist. Preview
the upcoming session and
then return to the dental
chair for treatment.
Appointment 3:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
Check medical/ Dental  LTG #2: (Desired outcome)- Begin patient ed session 3 by
history for any patient should have halt the reviewing the previous
changes since last progression of periodontitis and
session and reviewing any
visit, update intraoral reduce the plaque/bleeding previously learned skills
pictures of patient score. Gums should be in a (such as proxy brush).
conditions, update healthier state than the first Report to the patient what
plaque and bleeding appointment. Patient should be their plaque and bleeding
score, follow up on educated to know how score for that day are.
patient goals, whether periodontitis forms and how she(These will be taken before
patient has been can help reduce or most the session at the dental
successful with long importantly stop it. chair). Review goals from
and short term goals. session 2 and determine if
Check patient oral  STG: Patient should be able patient achieved those short
cavity health. to know how to floss -term goals. Provide positive
effectively and be able to feedback. If patient achieved
demonstrate it. long term and short term
goals then praise them as
 STG: Patient should be able they will continue to be
to know how to properly use motivated to perform good
the proxy brush and proper hygiene habits. Furthermore
brushing techniques. inform the patient of what
would of happened if the
patient has stopped
performing good hygiene
habits in order to motivate
them on continuing flossing
and brushing after the care
plan is over. Lastly evaluate
with the patient if the goals
where accomplished, If so
then dismiss the patient to
the dental chair for
treatment if needed.
Appointment 4:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
 LTG #3:

 STG:

 STG:

 STG:
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)

Based on this patient’s existing factors, her overall prognosis is Fair. This is due to her age
of 59, and had a broken rib which she is under the care of a physician for. Currently she is
taking phenytoin, which is one of the factors due to her gingival health and teeth
alignment. She is in the early stages of periodontitis and has poor oral hygiene habits such
as rarely flossing and brushing only once a day. She has a broken decayed tooth #3 and lost
6 teeth, mild bone loss and 4 mm depth pockets. Although patient has a history of not
being in a dental office for the past two years, she feels like she is strongly committed to
changing her oral hygiene habits and reduce her gingivitis.

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

Based on the dental health of the patient, I have made some suggestions on changing their
oral hygiene habits such as flossing at least twice a day with tooth pick floss but regular floss
would be recommended, also brushing twice a day for 2 minutes, and lastly using the correct
technique for optimal brushing such as the bass brushing technique. The third appointment
was a revaluation appointment in order to figure out where the patient is at with their
current oral state and how the progression of gingivitis to the early stages of periodontitis
can be stopped. The patient was then asked to demonstrate how to properly floss and brush
in order to measure the success of the care plan’s short-term goals. A referral was given in
order for the dentist to extract the decayed tooth #3 because of the future harm it can cause.
Since the patient was in the early stages of periodontitis the ideal recall time would be 4-5
months in order to check up on the patient’s oral health state.