1-368DENTAL HYGIENE CARE PLAN TEMPLATE

Care Plan submission will use findings from included patient information.
Student Name _Kaeli Bordelon
Patient Name__Kevin Johns Age_20_
Chief Complaint: “My gums bleed when I brush, and it hurts to floss.”
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. Broken collarbone from a car accident 1. pain, swelling, tenderness.

5 years ago.
2. Takes medication nifedipine for
hypertension and under care of a
physician.
3. BP is 140/89
4. Last physical was 2 years ago
5. Last dentist visit and x-rays was 3
years
2. nifedipine is used for hypertension. The
dose of the drug can affect gingival oral
growth, dry mouth, alterations in taste.
3. high blood pressure linked to gum disease.
4. at risk for undiagnosed diseases.
5. worsening issues, inadequate cleanings.

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.Increased risk for developing tooth decay.

1. Has had orthodontics 2. displacement of teeth
2. Had third molars were removed 3 3. needs updated x-rays to see if there are
years ago. new findings, risk for radiation exposure.
3. Has had FMX and pano taken 3 years 4. gingivitis, increased perio disease, plaque,
ago. bad breath, increased bacteria in oral cavity,
4. Brushes once a day and flosses plaque retention, bleeding, bone loss, caries
occasionally. 5. gingivitis, gum disease, advanced perio
5. Chief complaint is his gums bleed disease, plaque retention, bone loss
when he brushes, and it hurts to floss. 6.nutritional deficiencies
6. Eats out often
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. Bilateral, pea-sized palpable
submandibular lymph nodes.
2. Popping and clicking on the left TMJ.
3. Lower labial mucosa magenta and
reddened.
4. Tonsils are enlarged.
5. Reddened area bilateral anterior
tonsillar pillars.
6. Occlusion: class 1 right/left side;
canine and molar.
1.lymphadenopathy, infections.
2. pain, jaw damage, loss of bone and
cartilage.
3. epithelial atrophy, inflammation, reduced
keratinization
4. infection, interference with breathing,
sinus drainage, swallowing, and speaking.
5. oropharyngeal cancer
6. gum disease, affect chewing and speaking,
decaying teeth

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 disease, increased plaque,

1. Generalized moderate marginal and
papillary redness with rolled margins
and edematous papilla.
2. Localized severe redness facial and
maxillary anterior #6-#11 and
mandibular anterior #22-#26.
3. Gen 4mm pockets in posterior
4. Class 3 calculus
pockets depths, bone loss.
2. gingival disease, inflammation
3. at risk for plaque retention, perio disease
progression, bone loss
4. at risk for disease progression, plaque retention

a. Gingivitis _____ or Periodontitis Stage: 1 Periodontitis Grade: A

 b. Plaque Score: 4.5 Evaluation of plaque score: poor
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. Suspicious areas: 4-MOD, 5-DO, 29- 1.cavities, decay, tooth loss, pain
DO, 30-MOD

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. Mandibular lingual bar from #22-#27 1.caries, gingivitis, perio disease, plaque
2. Sealants on teeth #3, #14, #19 retention, calculus, inflammation
3. Missing teeth #1, #16, #17, #32 2. none
4. Suspicious areas: 4-MOD, 5-DO, 29- 3. teeth displacement and movement, food
DO, 30-MOD stuck in gums.
4. cavities, decay, tooth loss, pain, plaque
retention

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. Gingivitis, inflammation, bleeding dental cleanings
3. Caries 2. Plaque biofilm, moderate calculus, poor
4. TMJ popping, clicking homecare, medication
5. Enlarged tonsils/ swollen lymph nodes 3. Plaque bacteria, diet, infrequent plaque
removal, xerostomia, high risk
 4. Unknown, possible relation to car accident
or clenching and grinding
5. Unknown, possible illness, infection,
mouth breathing, etc.

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. medical and dental history Brushes once a day and flosses occasionally.
2. vital signs Gums bleed when brushing and it hurts to
3. Extraoral/intraoral exam floss.
4. perio assessment
5. perio/dental charting
6. plaque and bleeding score
7. informed consent and signature
8. treatment plan
9. risk assessment and signature
10. Take updated x-rays.

Appointment 2:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction_______
- Review Med/Dental  LTG #1: show patient how to
history correctly brush and will brush -Ask them if they know
Plaque and Bleeding twice a day using proper importance in oral home
scores brushing method care daily
Patient Ed #1 - -teach patient what plaque
Plaque/Toothbrushing  STG: decrease plaque score is and how destructive it can
Scale Maxillary Right from 4.5 to 3 by next be.
appointment
-tell patient dangers of
sugary drinks and carbs and
 STG: decrease bleeding
their effect on teeth.
score by 20% by next
appointment

 STG: ask questions to get an

 understanding about what
they already know.
Appointment 3:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction_______
Review Med/Dent  LTG #2: Teach patient the - Explain importance of
History importance of flossing and they brushing and demonstrate
Plaque & bleeding will understand the importance the correct technique.
score of plaque and how it affects oral
Patient Ed #2 - cavity.
Gingivitis/Periodontitis
and Flossing  STG: decrease plaque score
Scale Max left from 3 to 1 by next
quadrant appointment
Scale Mand left
quadrant  STG: decrease bleeding
score by 20% by next
appointment

 STG: be able to show be

proper flossing technique

Appointment 4:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction_______
Review Med/Dental  LTG #3: patient will continue -educate patient on how
History plaque removal by reducing periodontitis is not
Plaque & bleeding score to 0 reversible, but its
score progression can be stopped.
Patient Ed #3 - Caries  STG: teach patient the
Scale Mand right danger of periodontitis
quadrant
Plaque Free  STG: decrease plaque score
Fluoride Varnish to 0
Set recall appointment
 STG: decrease bleeding
score to 0

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. My patient is a young, twenty-year-old student and worker who does
not smoke. He has all his teeth, except for his wisdom teeth. He has no bone loss, and his
occlusion is a class 1. He works during the week and weekends and eats out at lunch and
sometimes during dinner. If he takes precautions with the drinks and food he ingests, and
stays on top of his oral home care, he can halt the periodontitis and gingivitis.

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

Kevin should come back every 6 months to stay on top of plaque and calculus and should be
expected back by 4/1/2024. He needs referrals on suspicious areas 4-MOD, 5-DO, 29-DO, 30-
MOD.