DENTAL HYGIENE CARE PLAN TEMPLATE

Care Plan submission will use findings from included patient information.
Student Name _Anna Seymour_
Patient Name_Mary Lowe___ Age_53 years old________
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: ______________

1. Hospital visit: broken ribs (6 mo. Ago) 1. at risk for osteoporosis, increased risk of
breaking bone again, pain/discomfort

2. Medication: phenytoin 2. causes swelling, tenderness, and bleeding

gingiva after use, headache, blurred vision,
nausea & vomiting, nervousness, gingival
3. Under physician care for seizures enlargement, drug interactions

3. increased risk of death or serious injury,

medical emergency in the dental office,
headaches, fatigue

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:_____________

1. infrequent dental visits, none in past two 1. plaque and calculus accumulation, perio
years disease progression, undiagnosed dental
conditions

2. Experiencing bleeding & tender gums 2. perio disease progression

3. Tooth #3 broken 3. infection in the tooth, chronic pain,

damaged blood vessels and nerves

4. brushes once a day/rarely flosses 4. plaque and calculus accumulation, bacteria

spread into gingiva and cause gingival disease

5. teeth shifting 5. problems with chewing, speaking, tooth

 decay, gum disease, or losing teeth

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:___________

1. large thyroid gland 1. can cause pressure on trachea and

esophagus

2. bilateral popping/clicking of TMJ 2. arthritis or osteoarthritis development,

jaw injury, chronic pain, clenching and
grinding of jaws

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:_______________

1. patient exhibits generalized moderate 1. gingivitis and progressing periodontitis,

marginal redness w/ rolled margins and infection and inflammation, tooth decay
edematous papilla

2. linguals of teeth #12-14 exhibit localized 2. gingivitis, tooth decay, tooth loss,
magenta color developing periodontitis

3. predisposing factors: calculus deposits and 3. gingivitis, progressing periodontitis, mobile

medication teeth, tooth loss

4. patient has generalized 4 mm pocket 4. increased plaque/calculus deposits,

depths on interproximal of all molars, and increased periodontal disease risk
localized 2mm facial recession on #24 and
#25

5. patient has biofilm retentive features such 5. increasing bone loss if not treated, tooth
as supragingival and subgingival moderate loss
calculus deposits, caries, broken tooth,
mispositioned teeth, periodontal pockets
6. radiographs show generalized slight
horizontal bone loss (<15%) 6. gingivitis or periodontitis,
 7. bleeding points generalized on
interproximal of teeth
8. CAL generalized on facial and lingual of all 7. gingivitis or periodontitis, loose teeth,
molars, and facial of mandibular anteriors tooth loss

9. calculus classification: moderate 9. gingivitis, periodontitis

subgingival and supragingival deposits (class
4)
a. Gingivitis _____ or Periodontitis Stage: I____ Periodontitis Grade: _B___
b. Plaque Score: _2.0______ Evaluation of plaque score: ___poor______
c. Bleeding Score: _64%_____
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:_________________

1. patient shows generalized slight horizontal 1. increasing bone loss if not treated, tooth
bone loss (<15%) loss

2. tooth #3 broken with radiographic decay 2. tooth loss, infection in the pulp, caries,
increased plaque accumulation, pain

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:___________________

1. amalgam restorations generalized 1. recurrent caries, increased plaque

posterior accumulation

2. broken tooth: #3 2. infection in the tooth, chronic pain,

damaged blood vessels and nerves, tooth
loss
3. missing teeth #1, #7, #10, #16, #17, #32
3. developing periodontal disease, triggering
bone loss, shifting teeth, food impaction
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. caries 1. plaque bacteria, inadequate oral hygiene

2. plaque and calculus
3. periodontitis, inflammation, bleeding
4. broken, decayed tooth
5. TMJ popping, clicking
home care, infrequent dental visits, existing
Amalgam restorations, recession
2. insufficient plaque removal, infrequent
dental visits
3. plaque biofilm, moderate calculus,
inadequate homecare, medication
4. plaque bacteria, insufficient plaque
removal
5. unknown, possible clenching and grinding

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:
1. review medical/dental history, take vital 1. Modify patients toothbrushing technique
signs and explain the significance of proper at
2. plaque and bleeding score home oral hygiene.
3. explain plaque retentive areas and show 2. recommend a power toothbrush
patient their specific areas 3. recommend floss picks for easier patient
4. explain to patient the dental flossing
considerations of taking her medication,
which causes gingival inflammation/bleeding
5. scale max. right quadrant

Appointment 2:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
1. disclosing solution to  LTG #1: reduce patients plaque
show patients plaque score by 50% by the end of 1. explain to patient the
buildup treatment importance of brushing twice
2. Scale mandibular rt. a day/flossing once
Quadrant and maxillary  STG: remove any 2. explain to the patient
rt. quadrant calculus/plaque biofilm deposits plaque formation and why it
in quadrant
 3. patient education on  STG: patient is able to is important to remove it
plaque accumulation understand importance of oral daily
and calculus formation hygiene care and plaque 3. revisit patients
4. fluoride treatment removal toothbrushing method and
why it needs to be revised
 STG: patient decreases plaque
score by 10%
Appointment 3:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
1. scale mand. Lt.  LTG #2: slow progression of 1. educate patient on proper
Quadrant periodontal disease by reducing flossing techniques and
2. patient bleeding score by at least 20% at different floss types that will
education for last appointment make it more motivating to use
periodontal disease
and how to slow her  STG: patient understands and is
progression able to perform proper
brushing and flossing
 STG: patients bleeding score is
reduced by 10%
 STG: composite filling on
broken tooth #3 to reduce risk
of infection

Appointment 4:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
1. scale max. Lt.  LTG #3: patient understands the 1. 3-month recall ensuring the
quadrant importance of regular dental patient has followed care plan
2. radiographs for bone visits, practices good oral home recommendations and keep
levels, caries, calculus care, diminished periodontal them in a pattern of visiting the
deposits dentist
disease
3. have patient brush
and floss to show me
 STG: reduce 4mm pocket
their technique
depths to normal limits (at
progress
most 3mm)
 STG: reduce any clinical
attachment loss
 STG: patient schedules next
dental visit

Appointment 5: (if needed)

Plan for Treatment: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
1. review patient 1. recommend 6-month
history recall to ensure patient
2. disclosing solution to compliance and practice
see if there is a regular dental visits
difference in plaque 2. review importance of oral
accumulation hygiene home care and
3. scale if needed proper toothbrushing
4. fluoride treatment technique

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)
I would classify this patient’s prognosis as good. I based this on the fact that the patient has only slight
radiographic bone loss despite being middle aged, patient does not smoke, has 26 natural teeth, and
is managing her systemic health conditions.

10. Supportive Therapy: State the suggestions made to patient regarding re-evaluation,
referral, and recall schedule. (Note: Include date of recall appointment below.)
For this patient, I referred them to the dentist for a composite filling on tooth #3, which is broken, to
reduce the risk of any infection. Since the patient states that it does not bother her, I can assume it is
not as severe, other whys I could refer to an oral surgeon for an implant. I also stated a 3 month recall
for a fifth appointment to ensure the patient has complied with the care plan since our last visit, and a
6-month recall keeping the patient in pattern of regular dental visits.