DENTAL HYGIENE CARE PLAN TEMPLATE

Care Plan submission will use findings from included patient information.
Student Name: Bianca Chaney
Patient Name: Candice Cass Age: 25
Chief Complaint: ‘’My gums bleed all the time”
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. Pregnancy 1. stress, gestational hypertension, illness
2. Prenatal vitamins (infections), postpartum depression, miscarriage,
3. Prescription med- Cyclizine nausea, fatigue, gingival inflammation and
bleeding, gag reflex, decrease OH motivation.
2. constipation, bloating, hives, hormonal
changes
3. drowsiness, blurred vision, migraines,
(xerostomia)- dry mouth

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. Existing occlusal restorations 1. Recurrent decay, sensitivity, porcelain
2. Bleeding gums fractures, sealant failures
3. Brushes twice daily 2. Gingivitis/perio- disease progression, biofilm
4. Does not floss daily accumulation
3. Improves gum health, reduce perio-disease
progression
4. Plaque retention, disease progression, increase
bleeding and inflammation, interproximal carries

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. Enlarged thyroid 1. Hyperthyroidism, tachycardia (fast heart rate),
2. right TMJ: popping and clicking weight loss, irritability, undiagnosed thyroid
3. Lower labial mucosa (magenta and reddened) disease, difficulty swallowing or breathing, goiter
 4. Tonsil removal (tonsillectomy) 2. chronic pain, limited chewing function,
5. Occlusion bruxism-wear, and tears
3. inflammation, oral ulcers (erythroplakia-
precancerous) atypical lesion, infection, or
immune reaction
4. upper respiratory tract disease, risk of COPD
5. tooth decay, jaw pain, headaches, poor facial
appearance

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 description: generalized marginal 1. Periodontal disease progression, increase
redness and edema bleeding
2. Localized severe papillary edema #29 to 30, 2. Bleeding disease progression, pain with OH,
with localized 5mm pocket pyogenic granuloma, increase plaque
3. Generalized 4mm pockets accumulation
4. Bleeding score 75% 3. Plaque retention, perio-disease progression,
5. Plaque score 55% bone loss
6. Class 2 calculus 4. Perio disease progression, noncompliance with
OH
5. Perio disease progression, caries, calculus,
disease progression, plaque retention
6. Disease progression, plaque retention

a. Gingivitis ___ or Periodontitis Stage: _1_ Periodontitis Grade: __A__

b. Plaque Score: __2.8__ Evaluation of plaque score: __Fair__
c. Bleeding Score: __75%____
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. 10% horizontal bone loss 1. tooth loss, mobility, perio disease progression.
2. Suspicious areas 2. plaque retention, pain, tooth loss, infection/
tooth abscess.
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 restorations 1. recurrent decay, tooth extraction, overhang,
2. Missing teeth plaque accumulation.
3. Suspicious area 2. shifting, supra-eruption, perio- disease
progression, malposition teeth.
3. decay progression, increased plaque retention,
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
2. Periodontitis, inflammation, bleeding 2. Plaque biofilm, improper plaque removal,
3. Caries pregnancy
4. Missing #12, 21, 28 3. Plague bacteria, xerostomia, previous risk of decay
5. TMJ popping, and clicking 4. Unknown reason for extractions-question
patient
5. Unknown, question patient about 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. filled out and review medical and dental Patient brushes twice daily morning and
history night with fluoridated toothpaste.
2. Head and neck/ intraoral exam
3. Vital signs Flosses 3-4 times weekly
 4. Risk assessment
5. periodontal assessment
6. periodontal and dental charting
7. plaque and bleeding
8. Informed consent
9. Take x-rays

Appointment 2:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
 LTG #1: Patient will provide Patient education on what
Plaque Score plaque removal by reducing the plaque is, formation, where it
assessment. plaque score to 0 by the end of sticks, and how to reduce it.
the appointment.
Bleeding score Demonstration of proper
assessment.  STG: Patient will understand brushing technique, on a
what plaque is and how it typodont, and watch the
Scaling upper right affects the oral cavity and patient brush at the sink and
quadrant. will be able to explain this by correct technique if
the end of this session. necessary. Also, introduce an
alcohol-free mouthwash that
 STG: Patient will increase is effective.
brushing frequency to twice
a day and demonstrate Discussion on the impact of
proper brushing method next plaque, and what plaque
the next appointment. accumulation can progress
to.
 STG: Patient will reduce
plaque score by 1% at each Addressing chief complaint
appointment. “Gingival Bleeding”.

Appointment 3:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
 LTG #2: Stabilize periodontal
Continue Scaling health. Review of daily oral hygiene
moving to Lower right practices. Educate on
quadrant.  STG: Further reduction in gingivitis/periodontitis.
plaque and bleeding scores.
Re-evaluate plaque Introduce flossing
and bleeding scores. techniques, along with
 STG: Patient demonstrates interdental aids.
improved brushing and
 Apply Fluoride flossing techniques.
treatment if necessary. Discuss the role of fluoride in
 STG: Establish maintenance caries prevention.
interval for periodontal
therapy. Reinforce the importance of
regular dental visits
(Especially while pregnant)
Appointment 4:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
Finish scaling the  LTG #3: Complete the removal of Tailored oral hygiene
remaining quadrants calculus and biofilm. instruction based on patient
(Upper left and lower progress.
left).  STG: Achieve consistent
3mm or less pocket depths. Explain required improved
Reassess pocket cleaning areas.
depths.  STG: No new carious lesions
at next visit. Educate on caries process,
Caries control with diet and its relation to oral
sealants.  STG: Confirm patients health.
understanding of oral
diseases. Provide guidance on
overcoming hygiene
challenges.

Appointment 5: (if needed)

Plan for Treatment: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
LTG: maintenance of Review of entire oral hygiene
Final evaluation of periodontal health at a good routine, including techniques
periodontal status. grade. and other oral health care aids.

adjust home care
regimen as needed.
address any
outstanding issues.
determine recall
interval.
STG: Patient is affective to
personalize home care
regiments.
STG: no bleeding upon
probing.
STG: no calculus present.
Discuss the results of good
oral hygiene.
Provide strategies for long
term oral health care,
reinforce the importance.
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)
Given the patient's overall good general health at age 25 with 25 teeth, there is absence of systemic
diseases, and commitment to oral hygiene, the prognosis is good. She has decreased pocket depths
mm (reduced bleeding points, stopped the progression of periodontal disease, decreased plaque
accumulation, stopped progression of bone loss on tooth #29 and #30, and will achieve dietary
change for reoccurring caries. Active engagement in the proposed treatment plan and consistent
home care are critical to maintaining oral health, especially in the context of pregnancy. She does feel
she can commit to maintaining her oral hygiene goals, even while working full time, but can be
complicated when the baby arrives.

10. Supportive Therapy: State the suggestions made to patient regarding re-evaluation,
referral, and recall schedule. (Note: Include date of recall appointment below.)
After the active phase of treatment, a 3-month recall is suggested to monitor the patient's
periodontal status closely. A referral to a dentist is needed for existing suspicious areas. This is
particularly important due to her pregnancy, which can affect gingival health. Instruction on proper
home care techniques will be reinforced during these visits, and any necessary adjustments will be
made to her personal oral hygiene routine. The next recall appointment should be scheduled
accordingly.