DENTAL HYGIENE CARE PLAN TEMPLATE

Care Plan submission will use findings from included patient information.
Student Name _Jing Zhang______________________
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: ______________

1. Hospital visit for a broken rib 6 months ago 1. Pain/discomfort

2. Seizures 2. The medication for rib broken recovery
3. Currently takes phenytoin may have an effect on the patient’s oral
health
3. Seizures-injury, medical emergency in the
dental office, headaches, fatigue
4. Medication: Phenytoin - headache, blurred
vision, nausea and vomiting, nervousness,
gingival enlargement, drug interactions

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 visit 1. Undiagnosed dental conditions, increased

2. Recently experienced bleeding and tender plaque and calculus, periodontal disease
gums 2. Periodontal disease, inflammation, non-
3. Tooth #3 was broken compliance with OHI
4. Brushing teeth once a day 3. Decay, further breakdown of tooth, pain,
5. Rarely flosses plaque retention
6. Teeth shifting recently 4. Plaque retention, disease progression,
inflammation, 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. Enlarged thyroid gland is at risk for

2. TMJ bilateral popping and clicking difficulty swallowing or breathing, goiter
2. TMJ is at risk for pain, difficulty chewing.
TMJ issues can permanently damage our jaw,
resulting in loss of cartilage and bone

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. Periodontal disease, inflammation, non-

marginal redness with rolled margins and
edematous papilla. Localized area lingual
teeth #12-#14 magenta color.
2. Patient shows generalized 4 mm pocket
depths on the DM surfaces of all molars.
Localized 2 mm facial recession #24 and #25.
Generalized bleeding on all of teeth.
3. Patient’s radiographic shows she has
generalized slight horizontal bone loss
(<15%).
4. moderate supragingival and subgingival
calculus (class 4).
5. Tooth #3 was broken with radiographic SA.
Amalgam restorations generalized on
posterior.
6. Teeth shifting. General CAL is 1.
7. Retentive features include calculus,
periodontal pockets, caries, amalgam
restorations and malpositioned teeth.
8. Predisposing plaque retention factors
include nutrition, medication, soft tissue
deformity, & defective contacts. Patient
exhibits poor oral hygiene care and
infrequent dental visit.
compliance with OHI
2. Retention biofilm, plaque, calculus, disease
progression, inflammation, teeth mobility,
interproximal caries
3. Caries progression, increased plaque
accumulation, increased caries risk, pain,
tooth loss
4. Inflammation, retention biofilm,
periodontal disease
5. Decay, further breakdown of tooth, pain,
plaque retention
6. Malocclusion, mobility, increased plaque
retention
7. Retention biofilm, caries recurrent
8. Inflammation, periodontal disease
progress, undiagnosed dental conditions
 a. Gingivitis _____ or Periodontitis Stage: _I___ 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 loss 1. Caries progression, increased plaque

(<15%)
2. Missing teeth #1, #7, #10, #16, #17, #32
2. Tooth #3 broken with SA
accumulation, increased caries risk, pain,
tooth loss
2. Perio disease progression
3. Decay, further breakdown of tooth, pain,
plaque retention

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 decay

posterior teeth
2. Missing teeth #1, #7, #10, #16, #17, #32
3. Broken tooth #3 with SA
2. Determine whether missing teeth is due to
periodontitis or due to congenitally missing:
Disease progression, shifting, supra-eruption,
malposition teeth, food impaction
Missing teeth can affect your ability to chew,
pose problems with speech, gum damage,
and cause insufficient bone growth
3. Caries, increased plaque accumulation,
pain, tooth loss

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
3. Broken, decayed tooth
4. TMJ popping, clicking
dental cleanings
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:
Medical & Dental History Brushes once/ day
Radiographs Uses toothpaste for sensitivity
Intra & Extra Oral Exams Flosses rarely
Dental Charting Moderate plaque present
Periodontal Assessment
Plaque & Bleeding Scores
Chairside patient education and OH evaluation
Risk Assessment
Informed Consent
Communication log
Patent release
HIPAA
patient practice form
progress note

Appointment 2:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
scale maxi right quad  LTG: Patient will improve plaque Review patient’s evidence-
and half of maxi left removal by reducing the plaque base data, states patient
quad, patient score to 0 by end of the main complaint, educate her
education treatment why she has tender gums,
how to treat it. States LTG
 STG: Patient will understand and STGs.
what plaque is and how it Explain what plaque score
affects the oral cavity and indicates and the importance
will be able to explain this of reducing it. Educate her
by the end of this session. the term of plaque. How
plaque forms? Where plaque
 forms? How to remove it?
 STG: Patient will increase Introduce and
brushing frequency to twice demonstrate the tooth
a day and demonstrate a brushing for plaque removal.
proper brushing method by Let patient demonstrate
the next appointment. on a typodont. Show the
 STG: Patient will reduce patient how to correctly use
plaque score by 1 at each brush and what kind of
appointment brush, techniques is efficient
for her. Invite patient to the
sink (hygiene student put on
gloves), disclose the patient
and ask her to look in the
mirror and identify areas in
her mouth where there is
plaque remaining. Ask the
patient to remove those
areas of plaque using the
tooth brush. Observe &
assess her ability to use tooth
brush in her own mouth.
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.
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________
Scale half of maxi left  LTG: Halt the progression of Begin patient ed session 3 by
quad and mand left periodontal disease by reviewing the previous session,
quad reducing the bleeding score ask patient what plaque is. And
to 0% reviewing toothbrushing
technique. Report to patient
 STG: Understand what what their plaque and bleeding
periodontitis is and the score for that day are. (These will
cause of periodontitis be taken before the session at
end of this session the dental chair). Review goals
from Session 2 and determine if
 STG: Reduce bleeding patient achieved those short-
score by 20% at each visit term goals. Provide positive
feedback. If patient did not reach
 STG: Demonstrate the goals, why? Provide
proper flossing technique additional instructions to assist
and start flossing once a patient in achieving.
day by next appointment Proceed into Patient Ed
session 3 by explaining
periodontal disease & the
inflammatory process to the
patient. Review what the STGs
will be and how they will help the
patient achieve the desired
outcome (the long-term goal).
Use patient’s probe chart as a
visual aide to show pocket
depths & bleeding points. Discuss
what the patient’s own bleeding
score means related to the
amount of inflammation. Discuss
with patient that her
periodontitis is at a Stage I, Grade
B, which means she has mild
bone loss, and a moderate risk of
disease 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.
Allow patient to answer open-
ended questions to assess her
understanding of periodontitis.
Introduce and demonstrate
the floss for interproximal plaque
removal. Let patient demonstrate
on a typodont. Show the patient

Appointment 4:
Plan for Treatment: Goals:
______________________________________________________Hygiene Instruction________
scale mand right quad  LTG: Have carious restored end
of the treatment
 STG: Understand the cause
of caries and relation on the
diet end of this session
 STG: Patient makes an
appointment with DDS for
caries restoration by next
appointment
 STG: Patient begins to use
how to correctly use floss and
what kind of floss is efficient for
her. Invite patient to the sink
(hygiene student put on gloves),
disclose the patient and ask her
to look in the mirror and identify
areas in her mouth where there
is interproximal plaque
remaining. Ask the patient to
remove those areas of plaque
using the floss. Observe & assess
her ability to use floss in her own
mouth. Redisclose the patient
and ask her to look in the
mirror and see if she was able to
remove the areas of
interproximal 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.
Preview the upcoming session
and then return to the dental
chair for treatment.
Plan for Education and/or Oral
Begin patient ed session
4 by reviewing the previous
session, ask patient
periodontitis questions. And
reviewing flossing technique.
Report to patient what their
plaque and bleeding score for
that day are. (These will be
taken before the session at
the dental chair). Review
goals from Session 3 and
determine if patient achieved
those short-term goals.
 daily fluoride rinse by next
appointment
Provide positive feedback. If
patient did not reach the
goals, why? Provide
additional instructions to
assist patient in achieving.
Report to the patient
their plaque and bleeding
scores for the day. Review
the goals of Session 4.
Educate patient what
carious is? How caries form?
Treatment options? How to
prevent caries?
Review the referrals for
the patient
Educate patient what is
fluoride? Purpose and
benefits of fluoride? Where
fluoride come from? What is
demineralization and
remineralization? Introduce
supplemental aids that may
assist the patient in better
plaque removal.
Recommend 3-month
recall, emphasize frequent
recall for perio. Recommend
a future consult with a
Periodontist due to severity
of disease.

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 dental and gingival problems, her overall prognosis is fair. The patient
is in stage III and grade B periodontitis, which means she has bone loss and is at moderate
risk of progression. Additionally, the fact that the patient is 53, the treatment will be far less
effective than in younger people. Patient have already has teeth shifting issue due to she lost
6 teeth. Patient has seizures, even though it is in well-controlled with prescription, but it is
still has more risk to progress periodontitis than other people. Patient has poor oral hygiene
habits that make the treatment couldn’t reach to the ideal level.

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

1. Due to patient’s systemic condition and effects of medication, a post-periodontal re-

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