DENTAL HYGIENE CARE PLAN TEMPLATE

Care Plan submission will use findings from included patient information.
Student Name _Leticia Santos ______________________
Patient Name_Price Amanda_________________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: ______________

1. Seizures 1. Injury, a medical emergency in the dental

2. Broken rib, 2020 office, headaches, fatigue
3. Prescription Med- Phenytoin 2. Pain/ discomfort
4. Irregular Dental care 3. Headache, blurred vision, nausea and
vomiting, nervousness, gingival enlargement,
drug interactions
4. Dental and tissue decay

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. Bleeding, tender gums 1. Periodontal disease, inflammation,

2. Last dental visit 2 years ago disease progression, non-compliance with
3. Broken tooth OHI
4. Brushes once/ day 2. Undiagnosed dental conditions,
5. Flosses rarely increased plaque & calculus, periodontal
6. Shifting teeth disease
3. Decay, further breakdown of tooth, tooth
loss
4. Plaque retention, disease progression
5. Plaque retention, inflammation,
periodontal disease progression,
interproximal caries
6. Malocclusion, mobility, increased plaque
 retention

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. Possible (Endocrine problems,

2. Bilateral popping and clicking of the inflammation or infection)
TMJ 2. Temporomandibular joint dysfunction

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. Generalized moderate marginal

redness with rolled margins and 1. Periodontitis, infection
edematous papilla 2. Plaque retention, periodontal disease
2. localized say area Lingual teeth #12 progression,
#14 magenta color 3. Sensitivity
3. Generalized 4mm pocket depths on 4. root caries, periodontal pockets,
the proximal of all molars localized bone loss
2mm facial 5. bleeding
4. Recessions #24 and 25
5. Class 4 calculus

a. Gingivitis _____ or Periodontitis Stage: _1___ Periodontitis Grade: __B__

b. Plaque Score: _2______ Evaluation of plaque score: __Fair_______
c. Bleeding Score: ___65%___
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. Generalized slight horizontal bone 1. Perio disease progression, bone loss,

(<15%) possible mobility, infrequent dental
2. #3 broken tooth with radiographic care
decay 2. Continue decay and risk of infection,
(carbohydrates, poor dental care, no
use of floss)

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. Existing amalgam restorations 1. Recurrent decay

generalized posterior 2. Disease progression, shifting, supra-
2. Missing teeth, #1,#7,#10,#16, #17, eruption and malposition of teeth,
#32 food impaction
3. Broken tooth #3 3. Decay progress

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. Plaque & calculus 1.Insufficient plaque removal, infrequent

2. Periodontitis, inflammation, bleeding dental cleanings
 3. Broken, decayed tooth
4. TMJ popping, clicking
2. Plaque biofilm, moderate calculus, poor
homecare, medication
3. Plaque bacteria, insufficient plaque
removal
4. 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 the Dental History clinic  Evaluate health condition

2. Vital sings  Habits
3. Head and Neck/intraoral and  Use of aids
extraoral exam  Bruising method
4. Plaque
5. Toothbrushing
6. Periodontal assessment
7. Periodontal and dental chart
8. Plaque score
9. Informed consent
10. Risk assessment
11. Radiographs

Appointment 2:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
 LTG #1: The patient will decrease We will start with patient
Medical/Dental plaque score to 0 and bleeding education by showing her
history, review of gums. Reduce pocket depth how to brush properly and
plaque and bleeding how to use additional
Education session (how  STG: The patient will supplements such as dental
to brush correctly) decrease the bleeding and floss, showing her didact
Scale Maxillary Right plaque by the next material, asking open-ended
quadrant appointment questions, disclosing, and
helping patient.
 STG: The patient will encourage and Motivate
understand the importance patient.
 of the correct brushing
technique

 STG: Patient will understand

and use supplemental aids to
improve healing of gums
Appointment 3:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
 LTG #2: Patient will decrease
slow perio disease by reducing By showing to the patient
Scale Maxillary and left bleeding score from 65% to 20% the x-rays and what the
mandibular quadrant, Pocket depth will reduce horizontal bone loss looks
patient ed. significantly from 4 at 2 like, we will show the
 STG: The patient will improvement in the
decrease at least 10% of periodontal pockets, as well
bleeding score each as how the use of dental floss
appointment using the helps to eliminate the plaque
correct brushing technique that accumulates daily.
and floss. answer any questions the
patient may have regarding
 STG: Patient will eliminate their dental hygiene, and
plaque interproximal daily help improve what they have
already learned.
 STG: The patient will use the
correct brushing technique
and continue to improve self
dental care

Appointment 4:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
 LTG #3: Patient will decrease all
bleeding areas and sensitive Emphasize to the patient the
Scale mandibular right regarding perio issues. Healthy importance of their
quadrant, patient ed. tissue and reduced pocket appointments every 6
depth. months, and refer to Dentist
to attend decay restorations,
 STG: Patient will understand cavities, and edentulous
the importance of dental spaces
visits

 STG: The patient will have

 new good new habits doing
the correct use of aids and
attending recall at least every
6 months

 STG: Horizontal bone loss will

not progress by maintenance
in any future appointment
and collaboration with
patient

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)

The prognosis is good

1. Due to the patient’s systemic condition and the effects of medication, a post-periodontal
re-evaluation is recommended for this patient. To assess gingival healing, plaque removal,
and goal progress.
2. Referrals to the patient’s general dentist were given for tooth #3.
3. Due to the periodontal diagnosis of Periodontitis, the recall schedule is set at 3 months,
until it is determined that disease progression has been halted.

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

Suggest to recall every 3 months to check the gum due to the medications or at least 6
months recall
The patient is suggested to go to the dentist to change the restorations and treat tooth #3