DENTAL HYGIENE CARE PLAN TEMPLATE

Care Plan submission will use findings from included patient information.
Isis Edwards
Student Name _______________________
Lori Davis
Patient Name____________________________ 25
Age_________
“My gums bleed all the time”
Chief Complaint: _______________________________________________________________
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. Prenatal vitamin & cyclizine 1. Prenatal vitamin – teeth staining,

2. 3 months pregnant sore mouth or gums/ Cyclizine – can
cause dry mouth, tremors - unusual
3. Gen. bleeding when brushing or
face or tongue movements
flossing 2. Gingivtis, gingival enlargement and
bleeding, periodontal infection,
enamel erosion, nauseas, fatigue,
increased gag reflex, and decreased
OH motivation
3. Gingivitis or periodontal disease or
hormonally changes

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. Gums bleed all the time 1. Gingivitis or periodontal disease,

2. Not flossing daily hormonally changes, inflammation,
3. MOD composites disease progression, decreased
motivation
2. Flossing incorrectly (floss cut) or not
flossing as frequently as needed,
plaque retention, disease progression,
increased bleeding, and inflammation,
interproximal cares
3. Recurrent decay
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 gland 1. Undiagnosed thyroid disease difficulty

2. popping & clicking on RT TMJ
3. Lower labial mucosa magenta and
reddened
swallowing or breathing, goiter, and
over or underactive glad or cancer
2. TMJ pain, TMD or malocclusion,
difficulty chewing, infection or
immune reaction
3. Infection or continued trauma and
immune reaction

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:_______________

The patient has generalized moderate From the periodontal assessment findings,
marginal and papillary redness with a smooth the patient is at risk for gingivitis or
and shiny texture and edematous/spongy periodontitis (inflammation), bleeding, pain,
consistency. The patient shows severe caries, decay, or pyogenic granuloma, bone
edematous papilla between #29 and #30. loss, progression of periodontitis, increased
From probing, the patient shows generalized plaque accumulation, and getting a higher
pocket depths of 4mm and some localized diagnosis without treatment.
5mm pockets. The patient’s chief complaint
was that their gums bleed all the time, so the
bleeding points were generalized. The
patient shows light supragingival and
subgingival calculus deposits (class 2).
a. Gingivitis _____ or Periodontitis Stage: __1__ Periodontitis Grade: __B__
b. Plaque Score: ___ 2.83____ 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 #29 D and 1. Progression of periodontitis, tooth

#30 M loss, mobility
2. Suspicious Area – 4 MOD, 5 DO, 29 2. Caries progression, increased plaque
DO, 30 MOD accumulation, increased caries risk,
pain tooth loss

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. Missing teeth #1, 12,16,17,21 1. Shifting, food impaction, malocclusion

2. MOD composites #3, 14, 30 teeth, disease progression, supra-
3. Caries 4 MOD, 5 DO, 29 Do, 30 MOD eruption, increased plaque retention,
periodontal disease progression
2. Recurrent decay
3. Decay, tooth loss, increase of plaque
attachment, caries progression,
increased plaque accumulation, pain

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 and slight calculus 1. Insufficient plaque removal

2. Periodontitis, inflammation, bleeding 2. Plaque biofilm, improper plaque
3. Caries removal, pregnancy
4. Missing #12,21,28 3. Plaque bacteria, xerostomia, previous
5. TMJ popping, clicking risk of decay
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:
M/D Hist. Brushes twice a day morning and evening.
Radiographs Uses fluoride toothpaste
Head and neck/extra/intra oral examination Does not floss daily
Dental charting
Periodontal assessment
Plaque and bleeding score
Chair side patient education and OH
evaluation
Risk assessment
Inform consent

Appointment 2:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
- Scale maxillary right  LTG #1: Patient will decrease *I will go over the LTG and
quad & patient plaque to 0 by end of treatment STG that I have planned out
education for the patient. Go over their
 STG: Patient will understand plaque scores and bleeding
M/D Hist. the important of removing scores.
Plaque and bleeding plaque and the proper
score and compare to technique at this *Then we will go over plaque
appt. 1 appointment
and the proper brushing
Local anesthesia (if
technique with open-ended
needed)  STG: Patient will
questions to ensure the
Scale maxillary right demonstrate brushing at this
Patient education #1 appointment patient is participating.
  STG: Patient will decrease
plaque score by 10% by each
appointment
Appointment 3:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
- Scale maxillary left  LTG #2: Patient will decrease
and mandibular left bleeding score by 50% by the
quad & patient end of treatment
education  STG: Patient will decrease
bleeding score by 10% at
M/D Hist. each appointment
Plaque and bleeding
score and compare to  STG: Patient will understand
appt. 2 what periodontitis is and
Local anesthesia (if demonstrate flossing at this
needed) appointment
Scale maxillary and
mandibular left  STG: Patient will add flossing
Patient education #2 more frequently into their
routine (1 to 2 per day) to
remove interproximal plaque progress to periodontitis. Use
daily following this
appointment 2
Appointment 4:
*Have the patient
demonstrate brushing to make
any modifications. I will
make the patient go to the
sink, disclose the patient with
the solution, and have them
brush as well.
*I will review the last set of
LTG and STG that I have
planned out for the patient. I
will then introduce the second
set of LTG and STG. Go over
their plaque scores and
bleeding scores. Show the
patient the deep pocket depth
findings and all of the
bleeding points.
*I will then introduce a new
topic about periodontitis, go
over gingivitis and
periodontitis, and educate the
patient on how gingivitis can
the patient’s x-rays to show
bone loss on #29 and #30.
*The next topic will be the
proper flossing technique,
educating the patient about
flossing and other interdental
plaque removal aids, and
motivating the patient to try
to floss more frequently.
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
- Scale mandibular  LTG #3: Get suspicious area *I will review the last set of
right quad & plaque checked by dentist and get LTG and STG that I have
free & patient consult for implants at the end planned out for the patient. I
education of treatment will then introduce the second
 STG: Help patient schedule set of LTG and STG. Go over
M/D Hist. appointment at this their plaque scores and
Plaque and bleeding appointment bleeding scores. Show the
patient the deep pocket depth
score and compare to
findings and all of the
appt. 3  STG: Have patient
bleeding points.
Patient education #3 understand how caries are
Local anesthesia (if formed and how fluoride will
needed) prevent them at this
Scale mandibular right appointment *I will introduce a new topic
Plaque free about caries and fluoride.
Fluoride varnish  STG: Patient begins to us Asking the patient open-
Set recall appointment fluoride rinse by following ended questions to get them
3 months out appointment involved with and familiar
with how caries is formed,
how to prevent caries, talking
about fluoride and the risk of
too much, and how
medication can make you
more prone to getting caries

*After the patient has varnish

placed on their teeth, I will
give post-op instructions.

*Not hot foods or

drinks

*No crunchy foods

*No alcohol

*No brushing or
flossing for the next
4–6 hours or until the
next day
Appointment 5: (if needed)
Plan for Treatment: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
 LTG #3:

 STG:

 STG:

 STG:

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)

I would say the prognosis is good. Due to the fact that she is already in the habit of brushing
2x a day. She would just have to adjust to reminder to also floss 1 or 2x a day. She is young in
age, has localized slight radiographic bone loss, is a non-smoker, has 25 natural teeth,
establish OH routine, compliant with recall appointments, and overall good systemic health.

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

Referrals to dentist were given for: 4-MOD,5-DO,29-DO,30-MOD, and possible consult for
implants to replace missing teeth #12,21,28. Recall schedule needs to be set at 3 months
until disease remains halted.