Patient Specific Dental Hygiene Care Plan

Patient Name: Age: 53 Gender: Female

Student Name: Karissa Grado Date: April 1, 2017

Chief Complaint: Needs cleaning, gums bleed

Assessment Findings

Medical History At Risk For

Pt. last physical in October 2016---------------------------------------- --Unknown
Pt. has herpes/cold sores-------------------------------------------------- --Postponed treatment when active lesion is present; risk for
Patient has had surgery (tonsils, wisdom teeth, leg, C-section, spreading infection
breast augmentation)------------------------------------------------------ --None

Social and Dental History At Risk For

Pt. smokes cigarettes (16 yrs. 1 pack-a-day) tried to quite 2x --Oral cancer, caries increase, xerostomia, plaque increase,
before--------------------------------------------------------------------------- slowed healing
Drinks alcoholic beverages 2-3x times a week----------------------- --Xerostomia
Last dental exam in January 2017 (crown)---------------------------- --None
Last x-rays November 2016 (FMX)-------------------------------------- --Caries, Periodontitis,
Gums bleed when flossing------------------------------------------------ --Gingivitis, periodontitis,
Defective restorations------------------------------------------------------ --Recurrent decay, trauma, losing teeth
Grinding teeth/Clenching jaws------------------------------------------- --TMJ issues, attrition
Teeth can be sensitive (cold)--------------------------------------------- --Sensitivity, pain
 Dental Examination At Risk For
Hypersthenic body type--------------------------------------------------- --None
Dry cracked hands (trauma/working outside)----------------------- --Infection in broken skin
Pt. has Mesognathic profile----------------------------------------------- --None
Scattered ephilids on face, neck, arms (sun exposure/age)------ --Skin cancer
Sclera slight redness (lack of sleep)------------------------------------- --None
Myopia (wears glasses)---------------------------------------------------- --Worsen; blindness
Tonsils have been removed----------------------------------------------- --None
Hard palate-whitish (raphe/rugae/incisive papilla)---------------- --Oral cancer
Buccal mucosa (linea alba-trauma)------------------------------------- --Infection or cancerous lesion
Grinding/clenching---------------------------------------------------------- --Attrition, TMJ issues
Class I occlusion-------------------------------------------------------------- --None
#19 has fistula (3 red dots on lingual side 1mmx1mm) -feels
like it has pressure when you touch, tissue inflamed------------- --Infection
Midline shift 1mm to left-------------------------------------------------- --Occlusion issues
Xerostomia (smoking)------------------------------------------------------ --Increases caries
Scalloped architecture----------------------------------------------------- --None
Whitened color of gingiva (localized red #19) ----------------------- --Oral cancer, infection
Edematous/spongy consistency----------------------------------------- --Inflammation, Periodontitis, Gingivitis
Smooth and shiny papilla/margins------------------------------------- --Inflammation, Periodontitis, Gingivitis
Stippled attached gingiva------------------------------------------------- --None
Generalized recession apical to CEJ on mand. ant. mand. and
max. molars and premolars----------------------------------------------- --Periodontitis
Generalized 4mm pockets (#15,#30,#31,#32)------------------------ --Periodontitis, inflammation, infection
Generalized bleeding points---------------------------------------------- --Periodontitis, Inflammation, Infection
Moderate horizontal bone loss (UR, UL, LL, LR, LA)---------------- --Periodontitis
Mild horizontal bone loss (UA)----------------------------------------- --Periodontitis
Loss of crestal lamina dura------------------------------------------------ --Periodontitis
Caries (LR) #30,#31,#29,#18)--------------------------------------------- --Recurrent decay, losing tooth
Home Care: Oral B soft manual tooth brush,
Circular/Horizontal brushing technique, brushes 2x a day,
flosses daily, no rinse, Crest 3D whitening toothpaste, No
fluoride, whitening strips-------------------------------------------------- --Toothbrush abrasion, Periodontitis, Caries increase, Calculus
buildup between teeth
Pt. has several restorations----------------------------------------------- --Recurrent decay
Periodontal Case Type: II Plaque Score: 2.3 Fair Bleeding Score: 5.7%

Gingival Inflammation: Generalized marginal

Biofilm: Generalized Moderate
Biofilm Retentive Features/Predisposing Factors: Calculus, defective restorations, malpositioned teeth, nutrition, tobacco use

Dental Hygiene Diagnosis

Problem Etiology

1. Plaque------------------------------------------------------------ --Daily oral home care, bacteria, not brushing properly

2. Periodontitis---------------------------------------------------- --Not brushing and flossing properly, bacteria/infection,

plaque/calculus buildup, bone loss, clinical recession

3. Caries-------------------------------------------------------------- --Daily oral home care, bacteria, recurrent decay, no fluoride,

not flossing properly, defective restorations

4. Tobacco Cessation---------------------------------------------- --Behavior change; social environment; will to quit

 Planned Interventions

Clinical Education Oral Hygiene Instruction

1. Plaque------------------------------------------------------ --Tooth brushing technique use 45 degree angle
Scaling hard deposit with circular motion focusing on 2-3 teeth at a
removal time (2 min.); daily plaque and biofilm removal;
Reduce plaque score at upcoming appointments
Polishing soft deposit
removal 2. Periodontitis---------------------------------------------- --Flossing technique (c-shape around tooth/see-
saw motion) halt the progression of bone
Fluoride application- loss/recession and reduce pocket depths from
strengthen/remineralize 4mm to 3mm or less

3. Caries------------------------------------------------------- --Flossing and referral for restorative care; get

defective restorations fixed causing recurrent
decay, daily plaque and biofilm removal between
interproximal spaces, brushing/ flossing
incorporate daily fluoride

4. Tobacco Cessation-------------------------------------- --Behavior change; social/environment change;

Ask, Advise, Assess, Assist, Arrange; Set quit date,
encourage patient at appointments, offer
services; Chew gum with xylitol when having
craving;
 Expected Outcomes
Goals
LTG 1: Reduce bacteria levels and reduce plaque score by .6
to reach a goal of 1.1 in 2 exams.
STG: Define plaque
STG: Correctly demonstrate proper brushing technique
STG: Reduce plaque score by
LTG 2: Halt the progression of Periodontitis by stopping bone 2. Demonstrate proper flossing technique;
loss and recession of gums. Reduce pocket depths from 4mm Evaluate patients flossing method, reduce
to 3mm or less.
STG: Define periodontitis
STG: Correctly demonstrate proper flossing technique
STG: Show an improvement in pocket depths and tissue
heights
LTG 3: Caries restored and defective restorations fixed
STG: Define caries process
STG: Use fluoride once a day at home
STG: Get carious lesions restored; save up money
LTG 4: Tobacco Cessation; stop smoking within a year
STG: Set quit date
STG: Encourage patient at every appointment
STG: Teach how to do self exams
STG: Reduce stain, plaque score, caries risk
Evaluation Method Time Frame
6 months
1. Demonstrate proper brushing technique,
evaluate patients brushing method and take
plaque score at next appointment to see if
patient applied their new knowledge. Daily
biofilm removal
6 months
pockets depths and stop bone loss/recession;
3. Referral for dental restorations on caries; use 3-6 months
daily fluoride on demineralized surfaces;
brushing and flossing; daily biofilm removal
4. Set quit date and see if patient still follows
through; encourage patient at every 9 months-
appointment to keep up with tobacco cessation 1 year
program; decrease stain, odor, caries risk;
Demonstrate knowledge of importance of self
exams for oral cancer
 Prognosis Explain your prognosis
Good The patient is willing to change and is showing great progress towards meeting her goals. I feel
Fair the patient will be successful in meeting her goals of reducing plaque score, halt the progression
Poor of periodontitis, and follow through with her tobacco cessation program. We are a team and
Questionable she is willing to put in the effort to make changes towards optimum oral health. Patient wants
Hopeless to have a healthy mouth and body.

Appointment Plan

Appt # Plan for Treatment Plan for Education, Counseling or Oral Hygiene Instruction
Periodontal debridement on maxillary left and right Reduce bacteria and lower plaque score after first
1 quadrant; check plaque score appointment; reduction in sub/supragingival calculus;
demonstrate proper brushing technique; evaluate patient
X X brushing with new technique, make sure to tell them to
incorporate it into daily oral home care; define plaque

Periodontal debridement on mandibular left and right
2 quadrant; check plaque score at beginning of appt.
X X
Significant reduction in bacteria and lowered plaque score
after 2nd appointment; reduction in sub/supragingival
calculus; demonstrate proper flossing technique; evaluate
patient using flossing technique, make sure they try to
incorporate this into their daily self care; define periodontitis

Selective polishing on all quadrants and tooth surfaces; Polish all surfaces to remove soft deposits/debris on tooth
3 fluoride treatment to remineralize teeth; check plaque surfaces; referrals for carious lesions/defective restorations
score; final appointment to be fixed; do fluoride treatment; define caries process; tell
patient to use daily fluoride for remineralization purposes;
X X recall 3-4 months
X X
 Tobacco cessation program; check plaque score and Begin tobacco cessation at final appointment and encourage
4 pocket depths/bleeding points; final appointment/ program at follow-up evaluation appointment; this will
evaluation check-up reduce bacteria, stain, risk for caries, xerostomia, odor, and
periodontal disease; recall 3-4 months

Referrals: DDS for defective restorations #29 & #30

Recall Interval: 3-4 month recall