DENTAL HYGIENE CARE PLAN TEMPLATE

Care Plan submission will use findings from included patient information.
Student Name: Tailynn Do
Patient Name: Rebecca A. Hanson Age: 25
Chief Complaint: 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. pregnant at 14 weeks 1. gum disease and cavities

2. nausea, fatigue, gingival inflammation and
2. cyclizine bleeding, increased gag reflex, decreased OH
3. prenatal vitamins motivation
3. nausea, fatigue, gingival inflammation and
bleeding, increased gag reflex, decreased OH
refelx

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. bleeding gums 1. perio disease progression, gingivitis

2. perio disease progression
2. existing restorations 3. perio disease progression, caries
3. does not floss daily
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. possible goiter, difficulty swallowing or

2. popping and clicking on the right TMJ
3. tonsils removed
4. lower labial mucosa magenta and red-
dened
5. Occlusion class I left/right
breathing
2. jaw pain, headaches, earaches, neck pain
3. Plaque retention, disease progression, in-
creased bleeding and inflammation, inter-
proximal caries

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 pe-
riodontal diagnosis. Correlate what the findings place the patient at risk for.)
Periodontal Assessment Findings At Risk For:_______________

1. generalized moderated marginal and pap- 1. periodontal disease progression

illary redness with edematous papilla; local- 2. increased bleeding
ized severe edematous papilla between 3. pain
tooth #29 and #30 4. pyrogenic granuloma
5. increased plaque accumulation
2. generalized interproximal 4mm pocket
depths with localized 5 mm between #’s 29
and 30, no recession present, not furcations
or mobility
3. light supragingival and subgingival calculus
deposits (Class 2)

a. Gingivitis or Periodontitis Stage: 1 Periodontitis Grade: B

b. Plaque Score: 5.5 Evaluation of plaque score: Poor
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. Cor-
relate what the findings place the patient at risk for.)
Radiographic Findings:___________________________At Risk For:_________________

1. 10% hor. bone loss #29-D & #30-M 1. tooth loss, progression of periodontitis
2. SA: 4-MOD, 5-DO, 29-DO, 30-MOD 2. caries, tooth decay

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. MOD composite restorations present on 1. periodontal disease

#3, #14, and #30 2. increased bleeding
3. pain
2. missing teeth: #1, #12, #16, #17, #21, #28, 4. interproximal caries
#32
3. SA: 4-MOD, 5-DO, 29-DO, 30-MOD

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 calculus 1. insufficient plaque removal

2. Periodontitis, inflammation, bleeding 2. plaque biofilm, improper plaque removal,
3. Caries pregnancy
4. Missing #12, 21, 28 3. plaque bacteria, xerostomia, previous risk
 5. TMJ popping, clicking 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, appropri-

ate 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/dental history 1. brushes twice a day
2. floss 3 or 4 times a week
2. vitals 3. uses fluoridated toothpaste
3. oral exam
4. periodontal exam
5. dental charting

Appointment 2:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
 Plaque and Tooth- ● LTG #1: patient will decrease modify patient’s TB tech-
brushing plaque score by 50% by the end nique, recommended power
of treatment toothbrush, demonstrate

● STG: patient will decrease recommend more frequent

plaque score by 20% by the plaque removal, explain
next appointment plaque retentive features
and demonstrate
● STG: patient will understand
and define plaque at this ap-
explain plaque theory, as
pointment open-ended questions, dis-
close, help pt. identity areas
● STG: eliminate and control of of plaque retention
systemic and local risk fac-
tors

Appointment 3:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
Gingivitis and Tooth- ● LTG #2: patient will slow perio introduce OH aide
brushing disease progression by reducing
bleeding score to 20% at the explain periodontitis disease,
reevaluation appt use patient’s X-rays to show
bone loss
● STG: patient will decrease
bleeding score by 10% at use patient’s probe chart to
each appt show PDs and bleeding
points
● STG: patient will use a OH
aide to remove interproximal recommend 3-month recall,
plaque daily emphasize frequent recall for
perio
● STG: eliminate and control of
systemic and local risk fac- recommend a consult with a
tors periodontist

Appointment 4:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
 Caries Process ● LTG #3: patient will reduce compare patient’s progress
bleeding score to 5% at the end
of treatment recommend 3-month recall,
emphasize frequent recall for
● STG: patient will decrease perio
bleeding score by 0%
recommend a consult with a
● STG: maintaining biofilm con- periodontist
trol

● STG: eliminate and control of

systemic and local risk fac-
tors

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)

fair; 25 years of age, 25 teeth, 14 weeks pregnant, class 1 occlusion, perio 1B

adequate control of etiologic factors, adequate patient self-care factors, less than 25% attach-
ment loss, class 1 or 2 less furcation involvement

10. Supportive Therapy: State the suggestions made to patient regarding re-evaluation, refer-
ral, and recall schedule. (Note: Include date of recall appointment below.)
1. no need for re-evaluation
2. refer to patient’s general dentist for suspicious areas, dental implants for missing teeth 12,
21, 28, and maybe orthodontics
3. recall: every 3 months (recall appointment: January)