Patient Specific Dental Hygiene Care Plan

Patient Name ___ Age ___65____ Gender: F

Student Name __Haleigh Turley___ Date ___2/15/17___

Chief Complaint: Time for cleaning

Assessment Findings

Medical History At Risk For

Last Physical Dec. 2015------------------------------------------------- Undiagnosed Conditions
Medications:
Amlodipine----------------------------------------------------------------- Frequent recalls, increased bleeding risk, gingival hyperplasia
Omeprazole---------------------------------------------------------------- Dry mouth
Vagifem--------------------------------------------------------------------- Frequent recalls
Fluticasone Propionate------------------------------------------------- Dry mouth
Hysterectomy------------------------------------------------------------- None
Excessive urination and thirst---------------------------------------- Dry mouth, diabetes
Sinus infections----------------------------------------------------------- None
REFLUX---------------------------------------------------------------------- Halitosis, GI distress, tooth erosion
 Social and Dental History At Risk For

Alcoholic beverages 2-4 per month--------------------------------- Increased bleeding, oral cancer, caries
Last cleaning: 5-16-16--------------------------------------------------- Perio, gingivitis, caries
Last FMX and Pano: Never--------------------------------------------- Caries, boneloss
Last BWX: 5-16-16-------------------------------------------------------- Caries, boneloss
Dry mouth ----------------------------------------------------------------- Caries, tooth sensitivity, tooth loss
Less than 2/3 sugar containing diet, drinks, or sports drinks
per week-------------------------------------------------------------------- Caries

Dental Examination At Risk For

Athletic---------------------------------------------------------------------- None
Skin and Nails: scattered ephelides--------------------------------- Cancer
Mesonathic---------------------------------------------------------------- None
Myopia left eye----------------------------------------------------------- Increased vision deterioration
Hyperopia right eye------------------------------------------------------ Increased vision deterioration
Bilateral lymphadenopathy------------------------------------------- Infection, weakened immune system
Ant/Post Pharyngeal Pillars slight redness----------------------- Infection, weakened immune system
Maxillary tuberosity----------------------------------------------------- TMJ, clenching, abrasion to tissue when eating
Lineal Alba----------------------------------------------------------------- Ulcers, clenching, TMJ
Salivary flow: Rt side more flow than left side------------------- Xerostomia
Mid-line shift 2mm to right-------------------------------------------- TMJ, malocclusion
Slight gen. biofilm-------------------------------------------------------- Gingivitis, perio, caries
Soft Tissue Exam: Surface texture: Smooth and shiny--------- Gingivitis
Margins: rolled local lower molars buccal------------------------- Gingivitis, perio
Recession: Gen 1-2mm------------------------------------------------- Perio
Gen 1-3mm pockets----------------------------------------------------- Gingivitis
Loc. #1 6mm pocket ---------------------------------------------------- Perio
Loc. Bleeding #1---------------------------------------------------------- Gingivitis, perio
Gen. mild horizontal boneloss LR----------------------------------- Perio
Loc. Moderate boneloss UR,LL #1 and #17------------------------ Perio
Furcation involvement Class 1 #18---------------------------------- Perio, possible extraction with progression of disease
Defective restorations #20 SA---------------------------------------- Recurrent decay, restorative work, faulty restoration
Attrition--------------------------------------------------------------------- Sensitivity, caries, clenching, grinding, TMJ problems,
restorative work, malocclusion
Missing #2,#16, #17------------------------------------------------------ Perio
Periodontal Case Type: Case 3 Plaque Score: 2.6 Fair Bleeding Score: 0%

Gingival Inflammation: #1 Local Papillary

Biofilm: Slight generalized
Biofilm Retentive Features/Predisposing Factors: Calculus, Defective restoration

Dental Hygiene Diagnosis

Problem Related to Risk Factors or Etiology

Plaque----------------------------------------------------------------------- Poor home care, improper brushing technique, improper

flossing
Improper flossing, poor home care, progression of disease
Periodontitis---------------------------------------------------------------
Xerostomia----------------------------------------------------------------- Medications
Recurrent decay --------------------------------------------------------- Caries, broken restoration due to clenching
 Planned Interventions

Clinical Education Oral Hygiene Instruction

Plaque------------------------------------------------------ Teach pt what plaque is. Improve patients
Scaling – hard deposit brushing technique.
removal Perio Disease--------------------------------------------- Teach pt definition of perio disease. Teach patient
how disease progresses. Teach flossing technique.
Polishing – soft deposit Xerostomia---------------------------------------------- Teach pt what Xerostomia is. Apply fluoride to
removal remineralize teeth and show aides to help
salivary flow.
Fluoride application
 Expected Outcomes

Goals Evaluation Method Time Frame

6 months
LTG 1: The patient will reduce the bacteria in her mouth and 1. At each appt use disclosing solution and
maintain a low plaque score of 1.0. evaluate plaque score. Pt will lower plaque score
at each appt until she reaches 1.0.
STG: The patient will define plaque and use a disclosing
solution to detect plaque in her mouth.
STG: The patient will correctly demonstrate sulcular
brushing in her mouth.
STG: The patient will lower his plaque score at each
appointment by .2 until she reaches 1.0.
LTG 2: The patient will halt the progression of his 2. At each appt pt will floss and evaluate
6 months
periodontal disease. bleeding score. Pt will improve bleeding score
until she reaches 2%. Floss two times per week.
STG: The patient will define periodontal disease.
STG: The patient will show an improvement in pocket
depths and reduce bleeding score.
STG: The patient will correctly demonstrate how to floss.
3. At each appt will emphasize need to reduce
LTG 3: The patient will control her Xerostomia. cariogenic foods and drinks. Instruct pt to chew
STG: The patient will define Xerostomia. sugar free gums and candies. Encourage non- 6 months
alcoholic mouth rinses such as biotene or GC dry
STG: The patient will relate Xerostomia to caries process. mouth gel. Explain importance of low plaque.
STG: The patient will properly use oral aides such as
biotene, she will avoid cariogenic foods and drinks, and
alcoholic mouth rinses. The patient will use a home fluoride
treatment.

Prognosis Explain your prognosis

Good During patients appt, she seemed interested in controlling Xerostomia. Patient understood
Fair good brushing habits and flossing are important. Discussed how Xerostomia, medications, and
Poor caries risk are related. Pt understood and would like to halt progression of diseases caused by
Questionable Xerostomia.
Hopeless

Appointment Plan

Appt # Plan for Treatment Plan for Education, Counseling or Oral Hygiene Instruction
 Evaluate pt brushing technique and teach patient sulcular
1 brushing. Explain why plaque score is an important tool and
M/D Hx how it is used.
Head/Neck/Intra Exam
Perio Assessment
Plaque Score
Dental Charting
Informed Concent

Update M/D Hx Educate pt about perio disease and systemic involvement if

2 Scale UR/UL disease progresses. Teach patient flossing, improving
flossing to four times per week.

Update M/D Hx Educate pt about Xerostomia. Relation to medications,

3 Scale LL/LR recurrent decay, and bone loss. Explain why increasing
Plaque Free salivary flow and staying away from cariogenic foods is
Fluoride treatment beneficial.

Referrals: SA #20

Recall Interval: 6 months