Patient Specific Dental Hygiene Care Plan

Patient Name: Age: 21 Gender: M F

Student Name: MacKenzie Locke Date: 2/28/2019

Chief Complaint: screening

Prophy Class: 3 Perio Class: 1

Assessment Findings

Medical History At Risk For

Last physical unknown ------------------------------------------------ Undiagnosed health conditions, in-office emergency

Patient takes Depo-Shot birth control ---------------------------- Xerostomia, headaches, nausea
Patient takes Sertraline 50 mg for an antidepressant -------- Xerostomia, drowsiness, loss of appetite
Patient takes Metronidazole 500 mg antibiotics for bacterial
vaginosis ------------------------------------------------------------------- Poor wound healing, bleed easily, xerostomia
Patient takes Vyvanse 40 mg for day-time ADHD medication--
--------------------------------------------------------------------------- Xerostomia, nausea, vomiting, dizziness
Patient takes Adderall 20 mg for night-time ADHD
medication----------------------------------------------------------------- Xerostomia, dizziness, nausea, vomiting

Patient has occurrence of cold sores ------------------------------ Infection, cancer, sensitivity

 Social and Dental History At Risk For

Last dental visit for a cleaning was Jan. 2015 ------------------- Undiagnosed health conditions such as periodontal disease,
calculus buildup, caries, infections, oral cancer

Last x-rays were Jan. 2015 -------------------------------------------- Undiagnosed health conditions such as periodontal disease,
infections, cysts, caries

Gums bleed when brushing/flossing ------------------------------ Gingivitis, infection, high bacteria count, periodontal disease,
interproximal caries
Teeth sensitive to hot, cold, sweets and pressure ------------- Caries, plaque buildup, recession, gingivitis
Clenches and grinds throughout the day ------------------------- Malocclusion, fractured/broken teeth, tooth pain, TMJ pain,
headaches
Patient states they had a possible cavity from the last dental
checkup -------------------------------------------------------------------- Bacterial infection, further advancement of current decay,
tooth loss, pain
Patient has decreased salivary flow from medication -------- Xerostomia, caries, high bacteria count
Patient drinks 1 sugar containing drink a day ------------------- Caries, demineralization

Dental Examination At Risk For

Body Type: Asthenic --------------------------------------------------- None

Scatter ephilids on both arms --------------------------------------- Skin cancer
Mesognathic profile --------------------------------------------------- None
Scattered ephilids on face and neck ------------------------------- Skin cancer
Scar superior to right eyebrow, eti: trauma --------------------- None
2mm papule inferior to bottom lip on the left side ----------- Skin cancer
1 mm papule on left cheek-------------------------------------------- Skin cancer
2mm papule on left chinline ----------------------------------------- Skin cancer
Patient wears glasses, myopia -------------------------------------- Worsening eye sight
Chapped lips from weather ------------------------------------------ Cracked, bleeding lips, sensitivity during cleaning, infection
Scattered ephilids on vermillion border -------------------------- Skin cancer

Lymphadenopathy on left side in submandibular lymph

nodes from allergies --------------------------------------------------- Discomfort, cancer
Tonsil inflammation from tonsil stones --------------------------- Sore throat, infection
Maxillary torus, vaulted palate ------------------------------------- Oral discomfort, trauma with x-ray equipment
Patient grinds night and day ----------------------------------------- Pain, headaches, attrition, TMJ pain
Patient clenches night and day -------------------------------------- Pain, headaches, attrition, TMJ pain
Occlusion on Molars: Right: 1, Left: 1 Occlusion on Canines:
Right: 1 , Left: 1 ------------------------------------------------------ None
Overbite: 2mm, Overjet 2mm ------------------------------------- None
Midline Shift 1 mm to the left --------------------------------------- None

Scalloped architecture ---------------------------------------------- None

Localized Red gingiva on #19,14,7, 8,2, 3 F ----------------------
Soft tissue consistency edematous/spongy #2,3,19,14 F and
#7,8 L -------------------------------------------------------------------
Localized smooth and shiny surface texture of papillary and
marginal #2,3,19,14,7,8 L--------------------------------------------
Stippled surface texture of attached gingiva --------------------
Papillary and margin shape localized bulbous and rolled
#7,14,27,26 F ----------------------------------------------------------
Generalized 4 mm pocket depths-----------------------------------
Generalized bleeding upon probing -------------------------------
Impacted wisdom teeth ----------------------------------------------
Widened PDL space #6,7,8,9,13,20,25,28,29 --------------------
Close root proximity on #16,17,32 -------------------------------
Cares #14 -----------------------------------------------------------------
Potential periodontitis, high bacteria count, increased biofilm
Potential periodontitis, high bacteria count, increased biofilm
Potential periodontitis, high bacteria count, increased biofilm
None
Potential periodontitis, chronic inflammation, high bacteria
count
Potential periodontitis, alveolar bone loss, high bacteria count
Potential periodontitis, high bacteria count, increased biofilm
and calculus
Infection, inflammation
Trauma, infection, progression of PDL widening
Inflammation, bone loss
Decay, infection, high bacteria count, pain, loss of teeth
Incisal attrition #7-10 and #22-27 ---------------------------------- Tooth fracture, tooth pain
Lingual retainer #22-27 ------------------------------------------------ Plaque buildup, high bacteria count

Periodontal Case Type: 1 Plaque Score: 1.3 Bleeding Score: 15%

Gingival Inflammation: Localized papillary and marginal inflammation on #7,14,27,6

Biofilm: Moderate generalized
Biofilm Retentive Features/Predisposing Factors: Calculus, caries, lingual retainer, medication, impacted 3rd molars

Dental Hygiene Diagnosis

Problem Etiology

Periodontal Case Type 1 – Gingivitis ------------------------------ Plaque buildup, calculus, poor brushing and flossing habits,
infrequent dental visits, high bacteria count

Poor home care, poor diet choices, infrequent dental visits,

Plaque ----------------------------------------------------------------------
plaque buildup, high bacteria count, uneducated on how to
prevent caries and what causes them

Impacted 3rd molars ---------------------------------------------------- Impacted wisdom teeth can cause decay, it can worsen
gingivitis due to deep pocket depths and it can increase the
bacteria count in the mouth
Infrequent dental visits ---------------------------------------------- Uneducated about the importance for regular 4-6 month recall

Planned Interventions

Clinical Education Oral Hygiene Instruction

Scaling – hard deposit
removal
Polishing – soft deposit
removal
Fluoride application
Plaque/brushing ------------------------------- Define plaque and use flipbook page on plaque
to teach the patient how plaque is contributing
to their gingivitis and calculus build up. Discuss
their plaque score, teach and show the patient
ways to reduce the plaque score by their next
visit. Teach Bass Method of brushing and have
the patient demonstrate in the mirror what they
have learned from the session.
Gingivitis/Flossing --------------------------------- Define gingivitis by using the flipbook page on
gingivitis to teach the patient how to halt it and
prevent the progression. Patient also needs to be
aware of how to properly floss around impacted,
partially erupted wisdom teeth and lingual
retainer. Use flipbook pages over brushing and
flossing to teach the patient effective techniques
to clean their teeth. Watch the patient
demonstrate these techniques in the mirror and
make any changes if necessary.

Caries/ Fluoride ------------------------------- Define caries by using the flipbook page on

caries. Review the brushing and flossing
techniques learned from the last two sessions.
Ask patient how they are doing with the Bass
method of brushing. Define what fluoride is using
the fluoride flipbook page. Use x-rays to show
the patient potential areas for caries. Explain
how impacted 3rd molars are more likely to
become infected and have carious lesions if not
cleaned properly. Teach the patient how to
reduce the chance of interproximal caries with
the flossing flipbook page. Demonstrate this on
typodont. Have the patient demonstrate the
flossing technique in the mirror and make any
changes if necessary. Encourage the patient for
correct technique demonstration and lowering
plaque score each appointment, if applicable.
Expected Outcomes
 Goals Evaluation Method Time Frame
1 month
LTG 1: Patient will understand what plaque is and maintain 1.Evaluate plaque score at every visit using the
a lower plaque score each visit. disclosing solution. Teach Bass method of
brushing and have the patient demonstrate it at
STG:Patient will be able to define plaque and use
every visit, make any changes if necessary
disclosing solution to detect plaque at the next
needed for a more effective plaque removal.
appointment.
STG: Patient will learn Bass method and be able to
demonstrate this method by the second appointment.
STG: Patient will lower their plaque score by 0.3 to
maintain a plaque score of 1 or better. 2. Evaluate the plaque score and have the
LTG 2: Patient will stop and reverse their gingivitis in two patient demonstrate Bass method they learned
months before the condition progresses into periodontitis. from the previous session. Make any changes if 2 months
necessary to improve brushing technique. Teach
STG: Patient will be able to define gingivitis and
proper flossing technique and evaluate at every
understand how to reverse it.
visit. Check pocket depths and evaluate bleeding
STG: Patient will demonstrate proper flossing techniques score.
and understand that flossing will reverse their gingivitis.
STG: Patient will keep regular 4-6 month recall
appointments.
LTG 3: Patient will have carie restored and impacted 3rd
molars removed. 3. Evaluate the plaque score and have the
patient demonstrate the brushing and flossing
STG: Patient will be able to understand and explain the
techniques they have learned from the previous 1 year
caries process by the last visit.
sessions. Make any changes, if necessary.
STG: Patient will continue the Bass method of brushing Patient will explain the importance of flossing
and proper flossing technique to reduce the chances of regularly. Teach the caries process to the patient
developing more caries. and the importance of having impacted wisdom
STG: Patient will schedule appointment at dental office teeth removed.
and with oral surgeon to have fillings and impacted wisdom
teeth removed.
 Prognosis Explain your prognosis
Good I believe the patient has a good prognosis. The patient has been very involved during every
Fair appointment on how to improve and maintain good oral health. I believe the patient will take
Poor the steps needed to prevent getting more caries. Patient shows interest in having carie
Questionable restored, as well as consulting with an oral surgeon for wisdom teeth removal.
Hopeless

Appointment Plan

Appt # Plan for Treatment
Medical and dental history with vital signs
1 Screening
Intra oral and extra oral exams
Start Periodontal assessment
Medical and dental history with vital signs
2 Finished periodontal assessment
Plaque and bleeding scores
Dental Charting
Informed Consent
Patient Ed session 1
Started scaling LR Quad
x Plan next appointment.
Plan for Education, Counseling or Oral Hygiene Instruction
Define plaque and use flipbook page on plaque to teach the
patient how plaque is contributing to their gingivitis and
teeth that could have potential caries.
Discuss their plaque score, teach and show the patient ways
to reduce the plaque score by the next visit.
Teach Bass method of brushing and have patient
demonstrate in the mirror what they have learned in the
session.
Plan next appointment.
Start the session by having the patient define plaque and
review the brushing method they learned from the previous
session. Ask patient how they are doing with the Bass
method of brushing and have them demonstrate in the
mirror again. Make any changes if necessary and encourage
patient. Define and explain gingivitis using the flipbook
page. Teach the patient how to reverse their gingivitis with
the proper flossing technique. Have patient practice and
demonstrate in the mirror.
 Medical and dental history with vital signs
3 Check plaque and bleeding score
Finished scaling LR quad
Started scaling LL and UL quads
Patient Ed session 2
Medical and dental history with vital signs
4 Plaque and bleeding score
Check pocket depths
Finished scaling LL and UL quads
Started and finished scaling UR quad
Polish
Floss
Apply fluoride varnish
Patient Ed session 3
Referrals: #14 O
Recall Interval: 4-6 months
Start the session by having the patient define plaque and
review the brushing an flossing techniques learned from the
previous sessions. Have them demonstrate the methods,
make any changes if necessary. Have patient define what
gingivitis is and how flossing is the only effective way in
removing gingivitis from the mouth.
Plan next appointment.
Start the session by having the patient demonstrate the Bass
method of brushing and flossing techniques learned from
the last three sessions. Define and explain what caries are
using the caries flipbook page. Use the patient x-rays to
show them where potential carious lesions could form. Talk
to them about the importance of brushing and flossing
properly and how to incorporate a fluoride mouth rinse into
their oral hygiene care routine.