Patient Specific Dental Hygiene Care Plan

Patient Name : Age :25 Gender: M

Student Name :Anabel Mendoza Date: 2-27-17

Chief Complaint: Behind on getting teeth cleaned due to work.

Assessment Findings

Medical History At Risk For

Pt. is not under care of a physician. Last physical 2006 ---------- Undiagnosed health problems, High bp, gingival inflammation,
Taking multivitamins------------------------------------------------------- Xerostomia, nausea

Severe headaches and migraines----------------------------------------
Allergic to Latex--------------------------------------------------------------
Head and neck pain: can be acute, frequent, severe, or
throbbing
Whole body: dizziness, lightheadedness, or malaise
Sensory: sensitivity to light, aura, or sensitivity to sound
Gastrointestinal: nausea or vomiting
Visual: distorted vision or seeing flashes of light
Also common: irritability, nasal congestion, or scalp
tenderness
Anaphylactic shock,
Skin: blister, rashes, or redness
Nasal: runny nose or sneezing
Also common: itching, throat irritation, or watery eyes

Social and Dental History At Risk For

Pt. drinks (2x a month)------------------------------------------------------ Heart: Cardiomiopathy
Arrhythmias
Stroke
High blood pressure
 Liver: Steatosis, or fatty liver
Alcoholic hepatitis
Fibrosis
Cirrhosis
Pancreas:Pancreatitis
Cancer: Mouth
Esophagus
Throat
Liver
Last dental exam in 2015(cleaning)------------------------------------- Breast
Last X-Rays 2015 (BWX---------------------------------------------------- None
Gums bleed------------------------------------------------------------------- Caries, periodontitis
Teeth sensitive to cold---------------------------------------------------- Gingivitis and periodontitis
Pt. has 3-4 teeth he was told were Watches---------------------- Tooth sensitivity and pain
Pt. drinks less than 2-3 sugar containing drinks per week-------
Caries
Increased biofilm, plaque, gingivitis, decay, periodontitis
Dental Examination At Risk For
Asthenic body type---------------------------------------------------------- None
Pt has damaged left wrist due to trauma Etiol-trauma----------- None
Pt has ephiledes on tip of pinky, pointer finger, and palm of right
hand---------------------------------------------------------------------- Skin cancer
Scattered ephilides on top of left hand(sun exposure)------------ Skin Cancer
Macule unilateral, right upper forehead above eye (3 mm)
(Sun exposure)--------------------------------------------------------------- Skin Cancer
Pt has mesognathic profile------------------------------------------------ None
Pt has unilateral blood vesicle on right side of face(round)------ Skin Cancer
Uvula is atypical in that its larger than normal---------------------- None
Pt. has vaulted hard palate----------------------------------------------- None
Pt. has bilateral scarring on lateral borders of tongue More trauma
Etiol:Trauma--------
Pt tongue thrusts when nervous---------------------------------------- Trauma, Open bite, malocclusion
Occlusion, Mesognathic canines class I tendency toward II----- None
Overbite: 4mm--------------------------------------------------------------- Attrition
Biofilm: Moderate, generalized----------------------------------------- Gingivitis, periodontitis
Biofilm retentive features: Calculus malpositioned teeth, caries,
and periodontal pockets----------------------------------------- Gingivitis, periodontitis, increased caries risk
Predisposing factors, Medications and mouth breathing-------- Xerostomia halitosis
Scalloped architecture----------------------------------------------------- None
Localized magenta-Max and Mand anteriors------------------------ Gingivitis, Periodontitis
Consistency-Edematous/Spongy---------------------------------------- Gingivitis, Periodontitis
Surface texture Papillary & Marginal Shape (Smooth/Shiny)--- Gingivitis, Periodontitis
Surface texture attached (stippled)------------------------------------ None
Shape, Papillae-bulbous--------------------------------------------------- Gingivitis, periodontitis
Margins rolled and thickened on anterior mandibular------------ Gingivitis, periodontitis
Class III calculus deposits-------------------------------------------------- Gingivitis, Periodontitis
Localized 4mm pocket depths on LL & LR molars------------------- Periodontitis, Increased plaque retention
Localized attrition on mandibular anteriors------------------------ Periodontitis
Class 1 perio------------------------------------------------------------------- Excess wear, decay
Gingivitis

Periodontal Case Type: 1 Plaque Score: 4 Poor Bleeding Score: 14.36%

Gingival Inflammation: Moderate

Biofilm: Moderate Generalized
Biofilm Retentive Features/Predisposing Factors: Calculus, malpositioned teeth, caries, medications, defective restoration,
periodontal pockets.

Dental Hygiene Diagnosis

Problem Related to Risk Factors or Etiology

1. Plaque/Calculus---------------------------------------------------- Bacteria, Home Care, retentive features, cavities, gingivitis,

periodontitis, systemic diseases
Bacteria, Home Care, retentive features, cavities, gingivitis,
2. Gingivitis------------------------------------------------------------- periodontitis, systemic diseases, xerostomia
 3. Defective Caries------------------------------------------------------- Overhang #2-D, Bacteria, retentive features, cavities,
gingivitis, periodontitis, systemic diseases, Xerostomia

Planned Interventions

Clinical Education Oral Hygiene Instruction

Plaque Teach proper toothbrushing technique. Pt was
Scaling hard deposit unaware gums need to be brushed too.
removal

Polishing soft deposit Gingivitis Flossing, halt the progression of interproximal

removal caries, minimize pocket depths to 3 mm.

Fluoride application
Xerostomia Being aware or oral side effects of herbs and
supplements. Encourage usage of fluoride.
 Expected Outcomes

Goals Evaluation Method Time Frame

End of
LTG 1:Mason will reduce plaque score to 2 by last visit. 1.Plaque Score
treatment
STG: Mason will be able to define plaque by second visit.
STG: Mason will correctly demonstrate brushing.
STG: Mason will demonstrate flossing by 3rd appointment. End of
LTG 2: Mason will halt the progressioin of gingivitis. 2. Gingivitis Treatment
STG: Mason will define gingivitis.
STG: Masin will correctly demonstrate flossing.
STG:Mason will show improvement in pocket depths by 1
point, and reduce bleeding score. 3.Xerostomia End of
LTG 3: Mason will use Xylitol gum to fight Xerostomia. treatment
STG: Mason will define xerostomia.
STG:Mason will buy gum with Xylitol.
STG: Mason will use Xylitol gum regularly to reduce
xerostomia

Prognosis Explain your prognosis

Good Patient has shown interest in learning about home dental care, but is afraid of the dentist.
Patient shows self-interest in improving oral health, but would have to be techniques that can
Fair be used at home. Such as proper brushing, flossing, and use of floride.
Poor
Questionable
Hopeless
 Appointment Plan

Appt # Plan for Treatment Plan for Education, Counseling or Oral Hygiene Instruction
1.Plaque
1 1. Patient Ed
2. Plaque Score 2. Proper Brushing Method
3. Scale Max rt

1. Gingivitis
2
1. Patient Ed 2. Flossing
2. Plaque Score
3. Scale Max Lt

1. Benefits of fluroide
3

1. Patient ed
2. Plaque Score
3. Scale Mand ll, lr

1,. Benefits of Xylitol

1. Plaque Score
2. Polish all 4 quadrants
4 3. Apply Fluoride

Referrals: Get wisdom teeth pulled, have defective caries replaced.

Recall Interval: 3-4 months.