DENTAL HYGIENE CARE PLAN TEMPLATE

Care Plan submission will use findings from included patient information.
Student Name ___Tina Nguyen___
Patient Name ____Smith, Mark_____ Age __48__
Chief Complaint: Mr. Smith’s chief complaint is, “My teeth are turning brown.”
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) Last physical was 12 years ago.
(2) Does not take any medications, not
under care of a physician.
(3) Smokes 1 pack of cigarettes daily.
(4) Blood pressure 150/99.
(5) Pulse 128.
(6) In between jobs and divorced.
(7) Likes to ride bikes and watch sports.
(1) Undiagnosed systemic conditions and
personal health.
(2) Unaware of any health issues.
(3) Possible chance of oral/lung cancer
and periodontitis.
(4) Stained teeth and mucosa and bad
breath.
(5) Heart disease, heart attack, stroke,
tachycardia, dizziness, medical
emergency.
(6) Loneliness and social confusion.
(7) Increase in sugary consumptions.
(8) Somewhat physically active.

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) Teeth are turning brown. (1) Due to consumption of tobacco

(2) Does not have dental exam or
prophylaxis in eight years.
(3) BWX and panorex taken 8 years ago.
(4) Previous amalgam restorations and
existing carious lesions.
products.
(2) Bone loss and plaque retention.
(3) Possible carious lesions, plaque
buildup and periodontitis disease.
(4) Checked for dental caries and bone
 (5) Missing teeth #3, #14, #18, #19.
(6) Drink socially.
loss.
(5) To repair or filled up dental caries.
(6) Could have been caused by trauma or
an etiology.
(7) Reduce the accumulation of plaque
and bacteria on the teeth.
(8) Due to plaque buildup that hasn’t
been remove and possible chance of
periodontitis. The gums are sensitive
and irritated.

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 linea alba. (1) White coated tongue is at risk for
(2) White coated tongue. halitosis.
(3) Class II left side molar and canine. (2) Bilateral linea alba is at risk for
(4) Class I right side molar and canine. irritation, oral lesions.
(3) Due to possible chances of trauma or
teeth grinding/clenching and
commonly found in tobacco users.
(4) Disocclusion.

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) Generalized moderate marginal and
papillary redness with rolled margins
and edematous papilla.
(2) Localized severe redness facial and
lower anterior #22 - #26.
(1) Patient is potentially at risk for having
severe periodontitis, or possible stage
III of periodontitis due to the listed
factors that are present in his case.
(2) Due to infection or disease that
 (3) Whitened marginal tissues on the
maxillary lingual.
(4) Calculus classification is moderate to
heavy supragingival and subgingival
deposits (class 5).
(5) Generalized 5mm posterior
interproximal pocket depth.
(6) Isolated 6mm #2-B and 6mm #32-D.
(7) Pocket depths of 5 – 6 for facials of
teeth #1 to #16 (excluding #3, #14).
(8) Pocket depths of 5 for lingual of teeth
#1 to #16 (excluding #3, #14).
(9) Pocket depths of 5 – 6 for lingual of
teeth #17 to #32 (excluding #18, #19).
(10) Pocket depths of 5 – 6 for facials of teeth
#17 to #32 (excluding #18, #19).
(11) CAL of greater than 5.
(12) Experienced bleeding and sore gums.
causes the margins and papilla to be
rolled or thickened along with the
color being red which is a sign of
irritation.
(3) Redness on the facial and lower
anterior indicates change in disease.
(4) Whitened marginal tissues on the
maxillary lingual is also another
indication of change in disease
regarding color of the tissues.
(5) Calculus classification is class 5 and
includes a large amount of calculus
that has been accumulated over a
long period of time and lacking the
removal of it due to not regularly
attending the dental office.
(6) Horizontal bone loss displayed
through the teeth and gums.
(7) Missing teeth of #3, #14, #18 and #19
could have been due to periodontitis
disease which is an indication of
periodontitis stage III (loss of equal to
or less than 4 teeth).
(8) Pocket depths of the facials and
lingual surfaces of the teeth ranges
between 5 – 6 which indicates
periodontitis stage III.

a. Gingivitis: _____ or Periodontitis Stage: __Stage III__ Periodontitis Grade: __C__

b. Plaque Score: __2.2 __ Evaluation of plaque score: __Fair__
c. Bleeding Score: __36%__

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) Horizontal bone loss 40%.
(2) Carious lesions of 15 MO and 28 DO.
(3) Amalgam restorations of 2 MOD and
31 MOD.
(4) Missing teeth #3, #14, #18, #19.
(5) All third molars are present.
(1) With 40% of horizontal bone loss,
then there is bone loss to the middle
third and apical third, this will cause
attachment loss.
(2) Carious lesions on the MO of 15 and
28 DO (cause possibly by tobacco use)
will cause tooth decay if not properly
restored and treated.
(3) Amalgam restorations on 2 MOD and
31 MOD were put into place to
restore previous lesions that could
have been a future potential threat.
(4) Missing teeth could have been caused
by trauma, etiology, or most likely
due to use of tobacco.
(5) Third molars are all present with
pocket depths of 5.
(6) Progression of periodontitis and tooth
loss.
(7) Progression of caries and increased
numbers of plaque bacteria.

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 on 2 MOD and (1) Amalgam restorations were

31 MOD.
(2) Carious lesions on 13 O.
(3) Missing teeth #3, #14, #18, and #19.
(4) All third molars are present.
(5) Increased plaque retention.
(6) Decreased caries progression.
previously placed to restore dental
caries on mesial-occlusal-distal
surfaces of #2 and #31. Recurrent
decay is always a possible risk for
amalgams.
(2) Carious lesions on occlusal of 13 could
have been caused by tobacco use,
lack of oral hygiene, or other
reasonings but left untreated could
 increase risk of tooth decay.
(3) Missing teeth #3, #14, #18, and #19
could have been caused by different
personal health factors or use of
tobacco.
(4) All third molars are present, but with
deep pocket depths and CAL.

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) Change to the color of brown in teeth. (1) Heavy use of tobacco, 1 pack daily,
(2) Bleeding, inflamed, and sore gums. and slow process of tooth decay.
(3) Horizontal bone loss, carious lesions. (2) Gums that are bleeding, inflamed,
(4) Moderate to heavy calculus deposits. and sore could be signs of disease and
(5) Pocket depths of 5 to 6 mm. plaque biofilm.
(6) Generalized stage III periodontitis. (3) Horizontal bone loss due to
(7) Smoking (chief complaint: staining) periodontitis that destructs the bone,
(8) Plaque accumulation. and carious lesions are because of
plaque biofilm or the history of
previously having them, also the use
of tobacco.
(4) Large accumulation of calculus is
because of inadequate homecare and
lack of regular dental visits for
removal.
(5) Pocket depths of 5 to 6 mm is due to
periodontitis and causes the teeth to
not be anchored down.
(6) Generalized stage III periodontitis is
due to lack of regular dental visits,
plaque and bacteria accumulation,
heavy amounts of calculus left on the
teeth, clinical attachment loss,
horizontal bone loss present, and
being a frequent smoker.
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) Reason for visit, address the patient’s (1) Suggesting the halt of tobacco use at
chief complaint. home.
(2) Collect demographic data about the (2) Suggest continue brushing twice a day
patient and if the patient wants to using the fluoridated toothpaste.
further with possible treatments at
this office once treatment has been
considered.
(3) List down medical, social, and dental
history of the patient.
(4) List down any risk factors of the
patient and note possible
connections.
(5) Document how and what is being
used at home regarding oral care.

Appointment 2: Plan for Education and/or

Plan for Treatment: Goals: Oral Hygiene Instruction
______________________________________________________ ________

Go over medical and dental  LTG #1: Decrease risk of
history once again. List down periodontal disease and
the patient’s plaque and how to correctly self-care
bleeding score. Readdress at home to not further
the chief complaint and start progress the disease along
working to improve the with evaluating their
situation. plaque and bleeding score.
 STG: Patient will learn
and understand their
personal situation and
how to properly brush
their teeth.
Review chief complaint from
session one and discuss what
will happen during this
session. After going over the
medical and dental history
and performing the intra and
extraoral examination,
discussing the results with
the patient for any positive
or negative findings during
this examination. Plaque
score and bleeding scores
should be present, and
 discussing with the patient
 STG: Patient will be what is a good/poor score for
educated about the each and how to improve if
accumulation of needed. Discuss how factors
plaque and how to such as tobacco (Mark’s case)
reduce it. plays a big role into why
periodontal disease is
currently present. View the
patient’s bone levels and
radiographs to notice any
other findings that can
impact the disease. Make
sure the patient fully
understands that some oral
diseases are reversible, while
others are not but to know
that there is always room to
improve. Make sure the
patient is aware of what
periodontal disease is
occurring and how to self-
care at home and to continue
with dental office treatments
if necessary. Also, note that
bleeding scores should
improve by next visit.

Appointment 3: Plan for Education and/or

Plan for Treatment: Goals: Oral Hygiene Instruction
__________________________________ ____________________ _______

Review the patient’s bleeding  LTG #2: Make sure the
score. Ask the patient how it
has been and if they have
noticed any personal
progress. Readdress the chief
complaint and notice if the
patient understands the
periodontal disease clearer.
Restore any of the lesions
that are present. Scale the
surfaces that contain calculus
patient is keeping up with
their homecare and seeing
if they have reduced some
of the factors that causes
periodontal disease.
 STG: Patient reduces
the consumption of
tobacco (Mark’s case).
After reviewing the patient’s
bleeding score, there should
be a sign of improvement if
all components are working
together. Allow the patient
to ask any concerns they may
have and fully educate them
about it. If improvement is
present, then give them the
positive feedback. See if the
gums are less inflamed, ask
and examine the mouth. Ask
about how have changes in
their homecare
improve/disapprove
regarding their situation.
Address any current concerns
the patient could have about
their progress.
Appointment 4:
Plan for Treatment:
____________________________________________________
Review the overall progress  LTG #3: Get the carious
of the patient and list down
all the changes that are
visible and present. Make
sure that all quadrants of the tobacco cessation therapy.
mouth have been properly
scaled and thoroughly
checked. Once again,
readdress the chief
complaint and see if changes
have been made regarding it
 STG: Patient’s plaque the patient if they’re
and bleeding score is bleeding less, and if they
now reduced have notice small changes.
(hopefully). Address a big concern such
as if the use of tobacco has
 STG: Patient can fully been reduced or not and how
demonstrate how they it genuinely plays a huge role
are brushing and in periodontal disease, see if
hopefully start the patient wants any help
incorporating flossing with tobacco cessation.
in their daily routine as Watch the patient
well. demonstrate how to brush
and floss with what was
suggested for homecare. See
if the patient is having any
difficulties in any oral care
and assist them with it.
Readdress the main goal of
the situation and how if it’s a
mild disease then it could be
reversible, but if it’s severe
then there is just chance of
reduction. Make sure the
patient is fully aware of all
their factors of the
periodontal disease.
Plan for Education and/or
Goals: Oral Hygiene Instruction
________
Patient is now fully educated
lesions restored. Keeping about their periodontal
the bleeding score down disease. Go over their
and eventually start a progress from the start to
current and look at their
improvement. Suggesting the
 STG: Patient will patient to have frequent
continue performing dental visits to check on the
the correct dental status and condition of their
homecare to reduce periodontal disease. Seeing if
the progression of the patient would consider
 and if future changes will
continue after. Inform the
patient (again) that their
periodontal disease isn’t
reversible, but change can
always make a big difference.
Help the patient if they’re
fully ready to stop using
tobacco products (Mark’s
case) and if they would like
any assisting during the
process. Ask the patient,
besides the use of homecare,
is there any other dental
concerns that they would
need with or is troubling
them.
periodontal disease tobacco cessation (Mark’s
(brushing twice and case) to overall help with his
flossing at least once a
personal situation
day). considering that is one of the
biggest factors. Letting the
 STG: Patient makes an patient know the outcomes if
appointment with DDS they do not take care of their
to get restorations for condition accordingly and
their carious lesions. what they could possible fall
back into. Reviewing their
 STG: Patient will have homecare routine and seeing
an interest in a if there is anything left to
tobacco cessation add. Making sure the patient
therapy and potentially does not have any discomfort
stop the usage of and see if their confidence
tobacco products. has risen from. Once again,
readdressing any comments
or concerns they could have
about their personal
condition.

Appointment 5: (if needed) Plan for Education and/or

Plan for Treatment: 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 the information given and the patient’s factors, the overall prognosis of Mr. Smith
would be considered fair. Mr. Smith is currently 48 years old and seems as he allowed
periodontitis stage III to become very endangering. He has four missing teeth, and heavy
biofilm with inadequate control. Mr. Smith tends to experience carious lesions and is a heavy
 tobacco smoker. His use for tobacco has played a huge role in getting him here to this
prognosis. He also has severe bone loss. According to his documentation, it appears that Mr.
Smith does not seem fit to commit towards a 3-month recall schedule and has a previous
history of not regularly attending dental visits. Mr. Smith’s condition does seem severe
considering he do show signs of periodontitis stage III.

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

Re-evaluation appointment: three to four weeks.

Referral: to a dentist for carious lesions, to a periodontist for periodontitis disease, and to a
professional for smoking cessation therapy.
Recall schedule: at least every three months and a continuing routine.
(Today’s date: November 08, 2023)
(Recall appointment: February 08, 2023)