DENTAL HYGIENE CARE PLAN TEMPLATE

Care Plan submission will use findings from included patient information.
Student Name Daniela Vargas
Patient Name Cobb, Jennifer 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. Taking phenytoin for seizures 1. Gingival enlargement with gingivitis,

2. Broken rib cardiovascular side effects, GI side
effects, hypotension, bradycardia, &
arrhythmias.
2. Pain while in patient chair, can
puncture the lungs, difficulty
breathing

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. Irregular dental visits 1. Tooth decay/loss, gingivitis,

2. Bleeding/tender gums periodontitis disease, plaque
3. Broken tooth #3 biofilm buildup, calculus, caries,
4. Shifting teeth undiagnosed conditions.
5. Rarely flosses 2. Gingivitis/Periodontitis disease
6. Brushing once daily progression
3. Infection, pain in tooth, throbbing
pain in neck, ear, jaw, and head
4. Tooth decay, gum disease, tooth
loss
5. Plaque buildup, calculus, caries,
gingivitis, periodontitis disease,
halitosis
6. Plaque biofilm buildup, calculus,
gingivitis/periodontitis disease
progression, caries
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 1. Difficulty swallowing, neck tightness,

2. Bilateral popping and clicking of TMJ neck pain, difficulty breathing, cancer
2. Jaw pain, limited chewing function,
bruxism-related wear on 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. Generalized marginal redness & 1. Periodontitis progression

localized magenta-colored margins
on lingual of #12, #13, & #14.
Generalized edematous and rolled
margins.

2. localized 2mm facial recession on 2. Tooth loss, caries, root exposure,

#24 & #25.
3. Generalized 4mm pocket depths on
interproximal spaces of molars.
sensitivity when brushing or flossing,
& tooth mobility
3. Periodontitis progression, tooth loss,
pain, halitosis, bone loss & swollen
gums

4. Generalized mild radiographic bone 4. Tooth loss, tooth mobility, tooth

loss <15% sensitivity, halitosis,
swollen/bleeding gums, & pain
when biting/chewing

5. Moderate generalized biofilm on #3, 5. Calculus, periodontitis progression,

#8, #14, #19, #24, & #30 caries, tooth loss, bone loss, &
recession
 6. #3 broken with radiographic decay,
biofilm retentive features including
calculus & periodontal pockets, &
generalized posterior amalgam
restorations.
6. Excessive biofilm, calculus,
periodontitis progression, caries,
recession, bone & tooth loss.

7. Predisposing factors include systemic

disorder, medication, & improper 7. Infection, tooth loss, systemic
home care. Patient exhibits fair disease, calculus, periodontitis
biofilm control, 65% bleeding score, progression, swollen/bleeding gums,
and infrequent dental hygiene care. & CAL

8. Maximum of 3mm CAL 8. Periodontitis, tooth mobility, & tooth

loss
9. Moderate supragingival and 9. Periodontitis, recession, caries,
subgingival deposits ( class 4) halitosis, & swelling/inflammation

10. Missing teeth #1, #7, #10, #16, #17, & 10. Disease progression, shifting, supra-
#32 eruption, malpositioned teeth, &
food impaction

11. Generalized bleeding 11. Periodontitis

12. Bleeding points: All present teeth 12. Periodontitis

except for #11
a. Gingivitis _____ or Periodontitis Stage: 2 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 mild horizontal bone loss 1. Perio disease progression, tooth loss,
<15% mobility, caries progression, increased
2. Broken tooth - #3 plaque accumulation
2. Infection, caries, pain in tooth,
throbbing pain in neck, ear, jaw, and
 head
3. Missing teeth: #1, #7, #10, #16, #17, 3. Disease progression, shifting, supra-
& #32 eruption, malposition teeth, and food
impaction

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, #7, #10, #16, #17, 1. Disease progression, shifting, supra-
& #32 eruption, malposition teeth, and food
2. Broken tooth - #3 impaction
3. Generalized posterior amalgam 2. Infection, caries, pain in tooth,
restorations throbbing pain in neck, ear, jaw, and
head, plaque accumulation, tooth loss
3. Overhangs, faulty restorations,
recurrent caries

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
3. Broken decayed tooth
4. TMJ popping & clicking
5. Bleeding/tender gums
6. Generalized Stage II-B Periodontitis
infrequent dental cleanings
2. Plaque biofilm, moderate calculus,
poor homecare, medication
3. Plaque bacteria, insufficient plaque
removal
4. Unknown, possible clenching &
grinding
5. Bacteria in plaque biofilm, biofilm
retentive features, inadequate
homecare, not flossing, & harsh
brushing techniques
6. plaque biofilm, infrequent dental
care, horizontal bone loss, clinical
attachment loss, systemic risk factors:
seizures, calculus & periodontal
 pocket retentive features

7. 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:
Complete M/D history, HIPAA, Patient Educate patient on radiographic findings
Appointment Practice, Informed Consent, Pt and briefly talk about causes/prevention of
Ed: risks & benefits of radiographs, & take findings.
radiographs.

Appointment 2:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
 LTG #1: Plaque score of 0 by end
Plaque & bleeding of treatment
scores  Introduce a new or
 STG: Reduce plaque score to different brushing
st
Scaling 1 quad - UR 1 by next appointment technique
 Discuss why brushing
Pt.ed: what is  STG: Brush 2x a day by next 2x daily is important
plaque/toothbrushing appointment  Inform Pt on fluoride
benefits and product
 STG: Include fluoride into options
home dental care by next
appointment
Appointment 3:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
 LTG #2: Reduce bleeding to 0%  Educate Pt on
by end of treatment gingivitis/periodontal
nd
Scaling 2 quad - UL disease causes,
 STG: Reduce bleeding by symptoms, &
Pt. ed: 50% by next appointment prevention
periodontitis/flossing  Reiterate the
 STG: Reduce bleeding by importance of
25% by next appointment flossing, introduce
 techniques,
 STG: begin to floss 1x daily supplemental aids,
by next appointment how-to, & time
availability to floss in
Pt daily schedule
 Speak about
importance of
flossing, frequency &
types

Appointment 4:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
 LTG #3: No calculus formation  Attend dental office
Scaling 3rd quad -LL by end of treatment every 3-4 months
until periodontal
Pt.ed: frequent dental  STG: reduce calculus status is improved.
visits/ calculus formation at home Continue dental care
to every 6 months to
 STG: attend office every 6 prevent excessive
months calculus or caries
formation.
 STG: attend office every 3-4
months

Appointment 5: (if needed)

Plan for Treatment: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
Scaling 4th quad - LR  LTG #4: Pt will be informed  Inform Pt about
of risks and will understand medication risks and
Pt.ed: Medications, what is needed for disease how to decrease
TMJ dysfunction to not progress any further possible side effects
by end of treatment related to oral
  STG: Pt is aware of TMJ health. Explain why
causes by end of treatment Pt is experiencing
 STG: Pt remembers TMJ problems and
medication risks by end of what can help.
treatment

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 patient’s existing factors, her overall prognosis is good. She has adequate self-
care ability, as well as control of etiologic factors. She also has less than 25% attachment loss
and is classified as a class I for furcation involvement. She is 53 years of age, has fair home
dental care, and her social history does not allow her much time to give her oral cavity the
attention it needs. She exhibits fair biofilm control and history of infrequent dental visits.
May experience gingival enlargement because of medication taken for seizures. She is
missing 6 teeth and has a broken tooth with radiographic decay. She experiences generalized
mild horizontal bone loss, generalized periodontal pockets in remaining teeth, and localized
recession. She is a full-time mother and housekeeper, works part-time, and actively
participates at her local church. Therefore, she has a busy schedule that doesn’t allow her to
keep up with her oral health.

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

1. Referral to dentist for broken tooth

2. Re-evaluation recommended to assess healing, plaque removal, and goal progress
Recall: 1-2 weeks
(Today’s date: 11/9/23)
(Recall appointment: 11/16/23)