DENTAL HYGIENE CARE PLAN TEMPLATE

Care Plan submission will use findings from included patient information.
Student Name ______Tina (Nghi) Ly_________________
Patient Name_______ Sandy Patterson _____________________ Age___43 years old______
Chief Complaint: _bad breath and stained teeth
___________________________________________________________
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) Rheumatoid arthritis (1) Pain, limited mobility and dexterity,

(2) Methotrexate (prescribed functional limitation on performing
medication) self-care tasks including personal
(3) Blood pressure was high; hygiene, dry mouth, fatigue,
Hypertension stage 1 insufficient plaque removal, TMJ/joint
(4) Chronic smoker (one pack a day) pain & inflammation, etc.
(2) Some major side effects are mouth
sore (mucositis or stomatitis), may
lead to small ulcers, yellow patches or
bleeding in the mouth. Methotrexate
may possibly affect immune system
and potentially lead to increased
infection susceptibility and delayed
healing ability, nausea, vomiting,
bleeding
(3) Hypertension stage 1 can increase risk
for adverse cardiovascular events
such as heart attack or stroke
(4) Smoking-oral cancer, high rate of
periodontal disease progression,
delayed healing, stained teeth &
mucosa, halitosis

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) Lack of regular dental care such as
dental exam, dental cleaning, and
flossing
(2) Tongue is discolored and coated
(3) Bad breath
(4) Sugary mints consumption
throughout the day
(5) Dental anxiety
(1) Bad breath, stained teeth, discoloration of
tongue, plaque and calculus accumulation,
may lead to gingivitis or periodontal disease
(2) May increase the risk of oral cancer
(3) Can be a warning sign of advanced gum
disease
(4) Tooth decay (caries)
(5) Procrastination and delay of dental
treatment which may lead to the adversity of
the condition

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) Hard palate: generalized slight
nicotine stomatitis
(2) Buccal mucosa: generalized moderate
to heavy brown stain
(3) Malocclusion class I right/ left sides;
molar and canine, with slight
mandibular anterior crowding
(1+2) Presence of this indicates individual
usage of tobacco products => put at risk for
several significant health issues including oral
cancer, gum disease, tooth decay, bad
breath, slower healing, reduced saliva,
cardiovascular diseases, respiratory issues,
and even cancer
(3)Tooth decay, losing teeth or developing
gum disease, can also affect how patient
chew food and how she speak, can damage
tooth enamel and cause problems with the
jaw such as TMJ affecting jaw joints and
surrounding muscles and ligaments

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) Gingival Statement: generalized
severe gingival enlargement
(2) Fibrotic, whitened marginal, papillary
redness with rolled margins
(3) Stippled attached gingiva
(4) Generalized maxillary and mandibular
probing depths of 5-6 mm with
localized bleeding
(5) Class 4 calculus, stage 3 and grade C
due to smoking
(1) In severe case, gingiva may
completely cover the crowns of teeth
causing gingivitis and even lead to
periodontal disease due to difficulty
of keeping teeth clean and even lead
to caries, and tooth eruption. It may
also cause functional difficulties, and
disfigurement.
(2) Difficulty in maintaining proper oral
hygiene which may lead to an
increased risk of gingivitis or
periodontitis, can also affect smile’s
appearance
(3) Normal, no risk
(4) Progression of gingivitis, there would
be attachment loss leading to
periodontal ligament and bone loss,
loosening of teeth and potential tooth
mobility or even tooth loss. It will also
makes it’s more challenging to clean
teeth => increase risk of cavities.
Localized bleeding can lead to painful
abscesses, pus formation and
potentially widespread bad breath
(halitosis)
(5) More likely to develop systemic
health conditions including diabetes
and heart disease

a. Gingivitis _____ or Periodontitis Stage: _3___ Periodontitis Grade: __B__

b. Plaque Score: _3.5______ Evaluation of plaque score: __poor_______
c. Bleeding Score: __16%____
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 30% horizontal bone loss (1) Periodontal disease progression,
(2) Poor plaque score tooth loss, and mobility
(3) Missing teeth (2) Accumulation of much dental plaque

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:
(1) Broken tooth-colored restorations
(2) Missing teeth
(3) Mandibular teeth crowding
can lead to gingivitis and also
periodontitis
(3) Progression of disease, shifting
position of adjacent teeth,
malposition of teeth, and missing
teeth can impair the ability to bite
and chew effectively => reducing
dietary choices and overall quality of
life. Changes in bite and tooth
alignment due to missing teeth can
contribute to TMJ problems causing
jaw pain and other discomfort
At Risk For:___________________
(1) Recurrent decay, at risk for plaque
retention, caries progression, further
breakdown of tooth and restoration,
tooth loss
(2) Progression of disease, shifting
position of adjacent teeth,
malposition of teeth, and missing
teeth can impair the ability to bite
and chew effectively => reducing
dietary choices and overall quality of
life. Changes in bite and tooth
alignment due to missing teeth can
contribute to TMJ problems causing
jaw pain and other discomfort
(3) Misalignment or overlapping of lower
teeth, can pose several risks to dental
health such as difficulty in cleaning
which may lead to increased risk of
gingivitis, malocclusion and even
tooth decay
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) Bad breath (1) Inadequate dental care and

(2) Stained teeth homecare, poor oral hygiene, buildup
(3) Gingival inflammation & bleeding of bacteria in mouth lead to gingivitis,
(4) Periodontitis and periodontitis, smoking cigarettes
(5) Missing teeth (number 19) (2) Retention of stained biofilm and
(6) Smoking calculus in teeth
(7) Plaque (3) Calculus & stained biofilm retention,
(8) Calculus inadequate dental care, and
(9) Broken restoration homecare
(4) Calculus & stained biofilm retention,
inadequate dental care, and
homecare, risk factors
(5) Gingivitis or periodontitis leading to
tooth decay
(6) Stress
(7) Inadequate dental care and
homecare, poor oral hygiene, buildup
of bacteria in mouth
(8) Inadequate dental care and
homecare, poor oral hygiene, buildup
of bacteria in mouth, and the
accumulation of plaque for a long
time without proper dental care
leading to the formation of calculus
(9) The structure integrity of tooth can be
compromised which may lead to
failure of restoration, or it may come
from trauma or injury

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:
Review medical/ dental history, Observe patient’s toothbrushing technique
Take vital signs to ensure the removal of most left over
Radiographs, record plaque and bleeding particles on tooth, Patient use power brush,
 score, oral hygiene evaluation but does not floss introducing flossing
Risk assessment and informed consent technique and also educate patient
Head and Neck intraoral and extraoral exam importance of tongue cleaning to improve
Observe patient’s toothbrushing technique bad breath, recommend more frequent
and suggest modification if needed plaque removal, and explain plaque
Periodontal assessment retentive features. Explain how the
Periodontal and dental chart accumulation of plaque leads to gingivitis
and periodontitis. Explain the concept and
effect of gingivitis and periodontitis on
overall dental health and smell of breath.
Ask open-ended questions, disclose, and
help the patient identify areas of plaque
retention
Appointment 2:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
Review medical/ Tobacco recession
dental history, take  LTG #1: Patient will be able Begin patient education
the plaque and to quit smoking cigarettes session 2 by reviewing the
bleeding score, patient and improve her breath by previous session and also
education, and reducing the plaque score any previously learned skills
instruction session. to 0 by the end of the such as flossing technique.
Ensure understanding treatment Report plaque and bleeding
of tobacco recession score for that day are to the
and plaque biofilm  STG: Patient will patient. Review goals from
Scale maxillary right understand the detrimental session 1 and determine
and left quadrant effects of cigarettes to her whether the patient’s short-
overall dental health and term goals were achieved or
cause bad breath not. Encourage and provide
positive feedback to
 STG: Patient will be able to motivate and provide
perform oral exam at home additional instructions to
to monitor any changes assist and support the
and provide immediate patient if she did not reach
feedback about process those previous goals yet.
and improvement Proceed to patient
education session 2 by
 STG: Patient will replace explaining the negative and
sugary mints with sugar- harmful effect of cigarettes
free gums as a substitute not only to overall dental
for cigarettes and will health but also overall
incorporate fluoride health. Emphasize smoking
toothpaste and mouthwash cigarette is one of the
to strengthen teeth reasons affect her breath

Appointment 3:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
Scale the mandibular  LTG #2: Patient will slow
right quadrant periodontitis disease
progression by reducing
plaque score by 50% final
reevaluation appointment
by incorporating many
good oral hygiene habits
and possibly cause oral.
cancer. Reinforce the
patient’s knowledge about
the negative effect of
tobacco, and determine the
patient’s willingness to quit
smoking. Compliment and
provide strong support if she
is willing to quit smoking
entirely after that
appointment. Ask the
patient to reduce the
amount of cigarettes she
smokes per week if she finds
it is impossible to stop
smoking right away. Teach
the patient how to perform
oral exam at home to
monitor any important
changes. Suggest many
different alternatives to
replace or limit her habit of
smoking cigarettes by
chewing sugar-free mint and
also promoting the patient
to eat various vegetable and
fruits that are good for oral
health. Educate and suggest
patient to incorporate
fluoride toothpaste and
mouthwash to strengthen
teeth and lessen the bad
effect of smoking cigarettes
to teeth.
Begin patient education
session 3 by reviewing the
previous session and also
any previously learned skills
such as toothbrushing
technique. Report plaque
and bleeding score for that

 STG: Patient will
understand the definition
of periodontitis and be able
to explain what she can do
to slow, stop, and prevent
the disease by the end of
this appointment. The
patient will understand
bleeding is a sign of
gingivitis and it can
progress to periodontitis
and even tooth loss due to
bone loss if left untreated.
 STG: Patient will be able to
demonstrate how to use an
interproximal brush as a
plaque removal aide and
also know how to use
water floss, and how to
incorporate tongue scarper
to clean and remove
plaque build-up for a better
smell and taste by the end
of this appointment
 STG: Patient’s bleeding
score will show a decrease
of 10% at each remaining
appointment to reduce the
inflammation of gum and
stop the progression of
gingivitis to prevent
periodontitis
day are to the patient.
Review goals from session 2
and determine whether the
patient’s short-term goals
were achieved or not.
Encourage and provide
positive feedback to
motivate and provide
additional instructions to
assist and support the
patient if she did not reach
those previous goals yet.
Proceed to patient
education session 3 by
explaining concept of
periodontal disease
inflammatory process to the
patient
Introduce water flosser to
help remove any leftover
particles on interproximal of
teeth. Explain perio disease
process, use patient’s xrays
to show bone loss and show
patient her probe’s chart to
show pocket depths and
bleeding points. Discuss with
patient that her
periodontitis stage and it
means she has severe bone
loss and a moderate risk of
disease progression. Discuss
the risk factors of
periodontitis and show the
risk assessment form as a
visual aide. Reinforce the
importance of plaque
removal and how it will
helps to slow the disease
progression. Show the
patient how to use water
floss or proxy brush to
remove those leftover
particle or biofilm stuck on

Appointment 4:
Plan for Treatment: Goals:
______________________________________________________Hygiene Instruction________
Scale mandibular left  LTG #3: Patient will have a
quadrant better breath, and overall
Patient education decreased bleeding area and
about the importance plaque score, reduced pocket
depth, reduced biofilm on teeth Encourage and provide
and interproximal surface
between teeth
 STG: Patient will be able to
efficiently perform all those patient to improve or modify
previous skills including
good toothbrushing and
flossing technique, using
tongue scraper, and also
incorporating fluoride
toothpaste and mouthwash bleeding score for that day
 STG: Patient will quit
smoking cigarettes entirely
or reduce the amount
interproximal area between
teeth, display those proper
technique on a typodont and
let the patient try it on
herself. Observe and assess
the effectiveness and
proficiency of her ability to
use the proxy brush or
dental floss in her mouth.
Show the patient the
technique slowly and step by
step again if she does not do
it effectively. Compliment
and provide positive
reinforcement if she does it
correctly. emphasize
importance of frequent and
regular return for
periodontitis. Preview the
upcoming session and return
to dental chair for treatment
Plan for Education and/or Oral
Review goals from session 3
and determine whether the
patient’s short-term goals
were achieved or not.
positive feedback to
motivate and provide
additional instructions to
assist and support the
oral hygiene skills including
toothbrushing and flossing
technique if she did not
reach those previous goals
yet. Report plaque and
are to the patient.
Compliment if there is a
positive progress in quitting
smoking.
 tremendously by only 2-3
cigarettes a month
 STG: Patient will understand
the importance of regular
dental care and dental visit
to ensure a good overall
dental health
or figure out what is the
patient’s struggle while
quitting smoking to find
alternatives helping her.
Recommend 3-month recall,
emphasizing importance of
frequent and regular return
for periodontitis.
Recommended a future
consult with periodontitis if
the condition does not
lessen or changes after those
previous appointments.

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 middle
age factor, generalized moderate radiographic bone loss. Furthermore, she is a chronic
smoker; has 28 natural teeth, insufficient plaque removal, infrequent dental care, and a
systemic condition/ medication with oral side effects and potential for delayed healing. She
also exhibits limited dexterity and mobility due to her rheumatoid arthritis condition making
it harder to perform daily oral hygiene. Moreover, there is inadequate biofilm control. The
side effects of the prescribed medication Methotrexate she is taking and her habit of smoking
many cigarettes possibly cause stomatitis. If stomatitis progresses, it can become painful
lesions or sore which makes it difficult for individuals to perform efficient oral hygiene. This
can result in inadequate cleaning of teeth leading to gingivitis and periodontitis. There are
severe bone loss and periodontal pockets in many teeth. She has limited ability to perform
oral self-care tasks. She has a history of infrequent dental visits and has not been to a dentist
for 10 years. She also has a bad and painful experience at a dental office previously.
10. Supportive Therapy: State the suggestions made to patient regarding re-evaluation,
referral, and recall schedule. (Note: Include date of recall appointment below.)

Due to her condition and stage of periodontitis, there should be regular 3 month recall to
slow and stop the periodontitis progression and improve overall dental health, it is
significantly important to have frequent and regular return for periodontitis. There is also a
need for consulting with the dentist regarding the mesial occlusal of teeth number 3, mesial
occlusal and distal of tooth number 5, and also the missing of tooth number 19. There is also
a need for appropriate medical professional for smoking cessation and habit control therapy.

It is necessary to schedule a re-evaluation appointment with the dental hygienist to assess

the progress of the periodontal treatment and overall condition of patient’s dental health.
There should a future consultation with periodontitis for further support and plan to control
periodontitis if the periodontal condition becomes more complicated and not responding
according to the treatment. Recommended a future consult with periodontitis if the
condition does not lessen or change after those previous appointment and treatment with
the dental hygienist