DENTAL HYGIENE CARE PLAN TEMPLATE

Care Plan submission will use findings from included patient information.
Student Name Andrea Cazares Puente
Patient Name Brown, Mabel Age 25
Chief Complaint: Bleeding 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. 14 weeks pregnant 1. Cavities, gingivitis, bleeding gums,

2. Prenatal vitamins xerostomia
3. Cyclizine 2. Itching/swelling in throat
3. Xerostomia, cavities

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, inflammation, disease

2. Existing restorations progression, decreased oral health
3. Does not floss daily motivation
2. Recurrent decay
3. Plaque retention, disease progression,
increased inflammation and bleeding,
interproximal 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. Enlarged thyroid gland 1. undiagnosed thyroid disease,

2. Popping and clicking at right jaw and difficulty swallowing or breathing
TMJ 2. TMJ pain, difficulty chewing
3. Lower labial mucosa magenta and 3. Infection, immune reaction
reddened
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. papillary redness with edematous 1. Inflammation in the gums, gum

papilla
2. localized severe edematous papilla
between tooth #29 and #30
3. generalized 4mm pocket depths with
localized 5mm between #29 and #30
4. Calculus detection – Class 2
disease, infection
2. Localized periodontitis, gum infection
3. Periodontal disease, gum recession,
halitosis, bone loss
4. Periodontal disease, cavities, tooth
sensitivity

a. Gingivitis _____ or Periodontitis Stage: I Periodontitis Grade: B

b. Plaque Score: 2.8% 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.
Correlate what the findings place the patient at risk for.)
Radiographic Findings:___________________________At Risk For:_________________

1. 10% horizontal bone loss 1. Progression of periodontal disease,

2. Suspicious areas tooth loss
2. Caries progression, increased plaque
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. Class I Occlusion 1. Cavities, gum disease, TMJ disorders

2. MOD composite restorations on #3, 2. Sensitivity, wear and chipping,
14 and 30 recurring cavities
 3. Missing teeth #1,12,16,17, 21, 28, 32 3. Shifting, TMJ disorders, gum disease,
4. Suspicious areas (4-MOD, 5-DO, 29- bone loss, cavities
DO, and 30-MOD) 4. Caries, gum disease, root resorption

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
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- will
question patient
5. Unknown, will 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:
1. Went over medical and dental history She brushes twice a day in the morning and
2. Vitals evening and she flosses three to four times a
3. Head and neck/intraoral exam week. I will observe her brushing method and
4. Informed consent if she is not using the modified bass
5. Risk assessment technique, I will teach her since it cleans both
 6. Perio assessment the teeth and the gums. I would also make
7. Plaque/Bleeding score sure she uses an antimicrobial mouth wash.
8. Perio/Dental Charting

Appointment 2:
Plan for Treatment: Goals:
______________________________________________________Hygiene Instruction________
 LTG #1: The main goal is to get
Medical/Dental History her bleeding score to a low
review score, since this is her chief
Patient education and complaint.
instruction session
Take bleeding score  STG: Patient will be able to
Begin scaling maxillary understand what plaque is
right quadrant and be able to understand
how to prevent it.
 STG: She will be able to
correctly show the new
brushing technique that I
taught her.
Plan for Education and/or Oral
I will use disclosing solution
to see if she is brushing
correctly. If she does it
correctly I will tell her she did
a good job. Next, I will
introduce her to the
toothbrushing PowerPoint so
that she gets an
understanding of what she is
doing. I will also introduce
the plaque PowerPoint so
that she understands that
plaque is the main cause to
many oral diseases.

 STG: Bleeding score will

decrease at each
appointment.
Appointment 3:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
Medical/Dental History  LTG #2: Make sure she is I will make sure she has an
review compliant with her flossing daily understanding of plaque and
Patient education and instead of 3-4 times a week toothbrushing and will ask
instruction session her a few questions to see
Take bleeding score  STG: Understand and be able what she remembers. I will
Begin scaling maxillary to say out loud the different also follow up with her
left quadrant ways to use floss. toothbrushing technique by
using the disclosing solution.
 STG: By this session, her In this session I will show her
bleeding score sould have the flossing powerpoint so
gone down at least 25% that she understands the
down. correct ways and different
ways to floss. I will also tell
  STG: She will have reduced
gingival bleeding from using
the proper toothbrushing
technique.
her to be careful with flossing
because she can get floss
cuts. If she does not pick up
on daily flossing, the plaque
can become calculus, and
then can become a bigger
problem like gum disease. I
will also introduce to her the
periodontitis PowerPoint
slide and touch a little bit on
gingivitis.

I will also explain her stage

Appointment 4:
Plan for Treatment: Goals:
______________________________________________________Hygiene Instruction________
Medical/Dental History  LTG #3: The goal is to prevent
review future cavities from forming.
Patient education and
instruction session  STG: She will understand
Take bleeding score what periodontitis is and
Begin scaling ways to prevent it from
mandibular left happening.
quadrant
 STG: Although she will have
her baby soon, I will make it
her goal to still care for her
oral health.
 STG: By this session her
bleeding score should have
gone down notably since her
first appointment.
and grade of periodontitis
and what could happen if it
progresses. She will continue
to brush effectively.
Plan for Education and/or Oral
In this appointment I will
follow up with her on
toothbrushing, flossing,
information about plaque,
periodontitis, and gingivitis. I
will introduce the caries
PowerPoint to her so that
she will know the importance
of preventing them. Since her
diet may be affecting her oral
health, I will let her know
that the foods we eat play a
big role in the possible
cavities.

Appointment 5: (if needed)

Plan for Treatment: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
 Medical/Dental History In this appointment I will
review  LTG #3: The goal is to prevent follow up with her on
Patient education future gum disease and maintain toothbrushing, flossing,
Take bleeding score oral health. information about
Begin scaling periodontitis and cavities,
mandibular right  STG: Have reduced and follow up on any diet
quadrant inflammation, bleeding, and changes. I will show her the
probing depths. gingivitis powerpoint in this
appointment. I want her to
 STG: At this point, I would know that although it is not
like for her to know ways to periodontitis, there could still
prevent this disease from be a risk of gum disease if
happening again. she does not take care of her
oral health.
 STG: By this session, her
bleeding score should be in
the healthy range.

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 this patient’s existing factors, her overall prognosis is good. She is still at a young
age of 25 and has a good chance at healing. She makes sure she goes to the dentist every 6
months for her dental checkup. She also brushes her teeth twice a day and does not smoke.
The medication that is taking part in her xerostomia is only being taken in the meantime for
nausea since she is pregnant. Since she has a good history with keeping up with her dental
appointments, I know she will be able to commit to come every 4 months.

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

I have recommended to her to change her toothbrushing technique, floss daily, understand
how to prevent periodontitis and gingivitis, and change her diet. If the disease does not get
any better after treatment, we will have to get her a referral to the periodontist. Her
appointments will be every 4 months: Appointment 1- 10/28/2023. Appointment 2-
2/28/2024. Appointment 3- 6/28/2024. Appointment 4- 10/28/2024. Appointment 5
2/28/2025. The ideal recall appointment will be in 3 months, so it will be on 5/28/2025.

Referral to dentist for 4-MOD, 5-DO, 29-DO, 30-MOD, possible consult for dental implants to
replace teeth #12, 21, 28 if space has not been closed due to orthodontics.