Patient Specific Dental Hygiene Care Plan

Patient Name : Age : 22 Gender: M F

Student Name : Kimberly Tran Date : 2/23/17

Chief Complaint: Cleaning and wisdom teeth

Assessment Findings

Medical History At Risk For

19. Last physical is Unknown-------------------------------------------> Medical problems unaware of

Social and Dental History At Risk For

92. Glums bleed when brushing and flossing-----------------------> Inflammation: gingivitis or periodontitis
93. Teeth feel sensitive to hot, cold, sweets, pressure----------> Hypersensitivity, plaque buildup, recession, gingivitis or
periodontitis, possible caries
99. drink diet or sport energy one time daily----------------------> Caries, hypersensitivity
100. Sometimes chews gums with sugar----------------------------> Caries, hypersensitivity
 Dental Examination At Risk For
Normal body type ---------------------------------------------------------> None
Pt. has Prognathic profile------------------------------------------------> Malposition teeth, attrition, TMJ problems
1cm localized hang nail on Lt. Hand on index finger eti: trauma-
----------------------------------------------------------------------------------> Infections
1cm generalized macules light brown/red on the face eti: sun
exposure----------------------------------------------------------------------> Skin cancer
Wears corrective lenses with stigmatism(myopia) eti:
developmental--------------------------------------------------------------> Loss of vision
Neck midline of occipital 3cm nodule lump (folliculitis) ---------> Cancer
Rt. Anterior tonsil 2cm larger than Lt. tonsil eti:
developmental--------------------------------------------------------------> Cancer, infection
Buccal mucosa slight linea alba white 1cm long eti: trauma----> Infection, cancer

Cleft on #5 #28 #21 #12---------------------------------------------------> Gingivitis and periodontitis, infection, caries

Red generalized mandibular Rt. & Lt. Lingual-----------------------> Gingivitis or Periodontitis
Edematous/spongy consistencygeneralized----------------------> Gingivitis or Periodontitis
Smooth and Shinygeneralized mandibular anterior fascial-----
---------------------------------------------------------------------------------->
Gingivitis or Periodontitis
Rolled generalized margins----------------------------------------------> Gingivitis or Periodontitis
Recessions #3 #5 #6 #11 #12 #19 #28 (all) facial-------------------> Periodontitis, increasing caries, hypersensitivity, root exposure,
infection, tooth loss due to mobility
UL UR LL LR generalized pocket depths 4mm -----------------------> Periodontitis, infection, tooth loss due to mobility
Generalized slight bleeding ----------------------------------------------> Gingivitis or Periodontitis, infection
Mild horizontal bone loss LA --------------------------------------------> Bone loss increased if periodontitis is halted
#17 #32 PE and Impacted/ #1 unerupted molar -------------------> Increased caries, malposition teeth, possible extraction

Periodontal Case Type: 2 Plaque Score: .83 (Excellent) Bleeding Score: 18.8%

Gingival Inflammation: Localized #25 fascial and generalized mandibular lingual -- marginal
Biofilm: Moderate generalized
Biofilm Retentive Features/Predisposing Factors: Calculus, malpositioned teeth, and periodontal pockets
 Dental Hygiene Diagnosis

Problem Related to Risk Factors or Etiology

1. Plaque ---------------------------------------------------------------------> Xerostomia, risk for caries, periodontitis, demineralization/eti:

Poor oral hygiene, poor brushing or flossing technique

2. Periodontitis (4mm Pockets) ---------------------------------------> Calculus, caries, xerostomia due to medication (can halt
progression; not irreversible)/Eti: bacteria, poor oral hygiene,

3. Caries ----------------------------------------------------------------------> Xerostomia, bleeding gums/Eti: Poor oral hygiene, poor

brushing or flossing, infrequent dental visits, no fluoride
rinse/bone disease/ edentulous/root caries
4. Impacted 3rd molars ---------------------------------------------------> Malposition of teeth, abscess, developmental, increase caries,
plaque or calculus build-up
 Planned Interventions

Clinical Education Oral Hygiene Instruction

1. Plaque a white, sticky film that sometimes appear colorless
Scaling hard deposit What is it that full of harmful bacteria
removal What it looks like The bacteria from the saliva and food that remains
What causes it on the tooth will multiply -- it can lead to gingivitis
Polishing soft deposit How to remove it or periodontitis
removal Remove my brushing and flossing properly

Fluoride application
3. Caries Cavity appears a brown, sticky, and a hole in tooth
Define it Reduce snacks in between meals so PH can return
What it looks like to normal
How it is caused Use of fluoride can restore the minerals, drink
Demineralization/Remineralization water in between meals, brushing 2x a day, and
flossing

2. Periodontitis Loss of supportive tissues that cause shrinkage to

What is it irreversible the gums and loosens the teeth can lead to loss of
How to halt it tooth attachment
Recall Treated by brushing and flossing, nutritious diet,
Antimicrobial regular dental visits
 Expected Outcomes

Goals Evaluation Method Time Frame

LTG 1: Reduce plaque Score by .1 each visit goal is a score of At 3rd apt./end of
1. Take a new plaque score at each
.7 or less by last visit treatment
appointment
STG: Define Plaque
STG: Discuss the importance of brushing 2X daily for 2min.
and flossing
STG: Correct patients brushing technique (bass method)

LTG 2: Halt periodontitis progression by next appointment

At 3rd
STG: Define Periodontal disease (loss of bone and gum) 2. New bleeding score/visual inspection of
appointment/end
STG: Teach the importance of flossing and correct gums at each appointment. Recall
of treatment
technique appointment 3-4 months
STG: Reduce Patients bleeding score by 1.0 each
appointment

LTG 3: Patient will have caries restores on #13, #17, #32, by 3. Referral for dental restoration on lesions; 6-9 months
the end of this year use of fluoride on demineralized surfaces
STG: Define Cavities
STG: Discuss acidic effects, diet, PH levels
STG: Preventative fluoride treatment, find DDS

Prognosis Explain your prognosis

Good The patients is aware of the risk factors of the caries or possible caries and will be treated by the
Fair end of this year. Pt is also willing to brush her teeth properly for 2mins, but will not apply to
Poor brushing her teeth 2x daily despite her busy schedule. Pt. will attempt to floss more often.
Questionable
Hopeless
 Appointment Plan

Appt # Plan for Treatment Plan for Education, Counseling or Oral Hygiene Instruction
Medical/Dental Hx Define Plaque
1 Pre-rinse X Teach proper techniques of brushing
Plaque Score Watch patient brush
Patient Education Adjust/Reeducation anything from previous session
Scale UR

Medical/Dental Hx Define Periodontitis

2 Pre-rinse X Teach proper technique of flossing
Plaque Score Adjust/Reeducation anything from previous session
Patient Education
Scale UL

Medical/Dental Hx Define Caries

3 Pre-rinse Teach patient about diet PH levels, acid attacks
Plaque Score X Find DDS, discuss payments, scheduling appointment
Patient Education Adjust/Reeducation anything from previous session
Scale LL

Medical/Dental Hx Plaque Free

4 Pre-rinse Fluoride
Plaque Score/Bleeding score Adjust/ Reeducation anything from previous session
Patient Education X
Scale LR

Referrals: oral surgeon #1, #17, # 32 & DDS for Caries #13, #17, #32 & need sealants done #15 #18, needs a redo filling on #2,#7
Recall Interval: every 3-4 months recall visits