Patient Specific Dental Hygiene Care Plan
Patient Name: Nike Spalding Age: 46 Gender: Male
Student Name: Kenva Smith Date: 2/28/2020
Chief Complaint: Cleaning
Prophy Class: 3 Stage: III Grade: C ASA: II
Assessment Findings
Medical History
#25 Pt is taking prescription medications perindopril,
carvedilol, and spironolactone for blood pressure. Pt is taking
cefadroxil for premedication due to hip replacement ------à
#27 Hip replacement in Dec 2001 and Oct. 2017; gastric sleeve
surgery in 2010; carpal tunnel surgery in 2017; rotator cuff
surgery 7-8yrs ago. ----------------------------------------------------à
#34 Arthritis ------------------------------------------------------------à
#42 Sinus problems ---------------------------------------------------à
#47 Eating disorder----------------------------------------------------à
#60 Herpes/cold sores ----------------------------------------------à
At Risk For
#25 Dangerously high blood pressure that may result in stroke or
heart attack. Orthostatic hypotension may occur. Blood pressure
medication can also cause xerostomia. If premedication is not
taken before appointment, patient is at risk for infective
endocarditis.
#27 Infective endocarditis, if antibiotic premed is not taken as
directed. Value of nutritional intake may be compromised due to
gastric sleeve surgery.
#34 Manual dexterity may be an issue when brushing and
flossing.
#42 Toothaches are more common when there is sinus
inflammation.
#47 Patient may not be getting adequate nutrients.
#60 Herpes lesions may appear in the mouth.
#63 Heart attack ------------------------------------------------------à #63 Heart attack, high blood pressure, and syncope while in the
dental chair.

#66 Cardiovascular disease ------------------------------------------à #66 Potential cardiovascular emergencies in the dental chair that
may include angina, heart attack, high blood pressure, and even
syncope

#72 High abnormal BP------------------------------------------------à #72 Rise in blood pressure to even higher, more dangerous levels
if given local anesthesia with epinephrine.

#77 Allergy to codeine----------------------------------------------à #77 Allergic reaction may occur if patient were prescribed pain
medications with codeine, e.g. Tylenol 3.

#82 Allergy to iodine -----------------------------------------------à #82 Allergic reaction may occur if post procedural rinse were
given that contains iodine.

Social and Dental History At Risk For

#85 Patient drinks alcoholic beverages about 4x a week ------à #85 Higher potential for xerostomia.

#88 Last dental visit was 1yr ago for a dental cleaning. -------à #88 Progression of periodontal disease and undiagnosed caries.

#91 Last FMX was Sep. 2018 -----------------------------------------à #91 Progression of periodontal disease and undiagnosed caries.

Dental Examination At Risk For

-Blindness in the right eye ---------------------------------------------à -Problems with depth perception

-Generalized ephelides on arms from sun exposure-------------à -Skin cancer

-Popping in TMJ-----------------------------------------------------------à -Pain, headache, TMJ soreness

-Myopia --------------------------------------------------------------------à -None

-Walks with a limp due to hip replacement ----------------------à -Falling from a misguided step

-Circular white lesion on lower lip on the right side that is

benign (patient had it examined before) -------------------------à -None

-Exostosis near mandibular anterior teeth ----------------------à -Periodontal disease due to food buildup in area with exostosis.

-Scalloped tongue due to clenching ------------------------------à -TMJ pain, soreness, and headaches.

-Mucocele ---------------------------------------------------------------à -None

-Xerostomia--------------------------------------------------------------à -Increased risk for caries

-Bilateral linea alba ----------------------------------------------------à -None

-Missing teeth----------------------------------------------------------à -Super eruption and shifting of remaining teeth. Potential for
decreased nutritional intake.

-Occlusion right canine class 1; right molar class 1; left canine -None
class 2; left molar unclassifiable. -------------------------------------à

-Midline shift unclassifiable due to diastema---------------------à -None

-Overbite and overjet 3mm -------------------------------------------à -None

Periodontal Case Type: Stage III Grade: C Plaque Score: 1.2 (good) Bleeding Score: 17%

Gingival Inflammation: Generalized papillary and marginal

Biofilm: Slight localized on # 2, 3, 32
Biofilm Retentive Features/Predisposing Factors: Calculus, malposition teeth, prosthesis, and periodontal pockets
 Dental Hygiene Diagnosis

Problem Etiology

Periodontal stage 3 grade C -------------------------------------à Infrequent dental visits, calculus, (previous) poor brushing and
flossing habits, diet, high bacteria count, high oral bacterial
count.

Developmental. Inadequate plaque removal, biofilm retentive

Plaque -----------------------------------------------------------------à features such as calculus, infrequent dental visits,
Developmental or diet. Poorly controlled hypertension can
Hypertension--------------------------------------------------------à result in blood pressure levels raising o dangerous levels while
in the dental chair.

Trauma. Antibiotic premedication needed before treatment to

Hip Replacement ------------------------------------------------------à prevent infective endocarditis.

Arthritis -----------------------------------------------------------------à Developmental. Can pose limitations on manual dexterity

Sinus Problems---------------------------------------------------------à Developmental. Can cause toothaches in the maxillary posterior

regions.

Missing Teeth------------------------------------------------------------à Poor oral hygiene & infrequent dental visits. Inadequate
nutrition may be a result.
Medication. May result in caries.
Xerostomia-------------------------------------------------------------à

Biofilm retentive feature that can cause irritation, inflammation,

Restorations/prosthesis----------------------------------------------à
and recession. Recurrent carries may also occur.
Abrasion ------------------------------------------------------------------à Too much friction and pressure while brushing. Can remove
tooth structure along the gingival third and cause sensitivity if
enough enamel is warn away.

Planned Interventions

Clinical Education Oral Hygiene Instruction

Scaling – hard deposit
removal
Polishing – soft deposit
removal
Fluoride application
Plaque ----------------------------------------------------à
Define plaque and use flip book to teach the
patient how plaque is contributing to their oral
conditions, such as periodontitis. Discuss plaque
score, teach and show the patient ways to reduce
the plaque score by the next visit. Praise patient’s
use of Bass technique. Have patient demonstrate
use of bass in the mirror, and make any necessary
adjustments.

Periodontitis---------------------------------------------à Start session by asking patient to define plaque.

Affirm his use of bass technique. Define
periodontitis and use flipbook to aid in patient
education. Teach patient how to floss. Mention
the importance of interdental plaque removal
and enlighten him on the repercussions of not
flossing.

Xerostomia-----------------------------------------------à Start session by having patient define

periodontitis. Define xerostomia and use flipbook
as an aid. Explain that the patient is currently
experiencing xerostomia due to the medications
they are taking. Give suggestions on how to
manage and treat dry mouth and it’s effects (e.g.

Expected Outcomes
Goals
LTG 1: Mr. Williams will lower his plaque score to below 1 by
the end of treatment.
STG: By the next appointment, Mr. Williams will be able to
define plaque and identify it with the help of disclosing
solution and a mirror.
STG: He will demonstrate the bass technique and how to
effectively remove plaque.
STG: By the next visit Mr. Williams will increase his brushing
from once to twice a day at least two days per week.
LTG 2: By the end of treatment, Mr. Williams will halt the
disease state of his periodontitis to become a stable
periodontitis stage 3 grade C.
STG: By the end of the appointment the patient will be able
to define periodontitis and understand that it will worsen
unless he improves his oral hygiene and has regular
professional cleanings.
STG: Mr. Williams will be able to demonstrate proper
flossing, and w
STG: Mr. Williams will reduce his bleeding score from 17% to
13% by the last appointment.
LTG 3: By the end of treatment, Mr. Williams will be able to
manage his dry mouth and will be aware that xerostomia
can cause cavities.
biotene products and frequent sips of water,
avoiding alcohol mouth rinses which will add to
the dryness).
Evaluation Method Time Frame
1. Evaluate Mr. William’s effectiveness at plaque
Next visit
removal by taking a plaque score using disclosing
solution and a mirror. Reinforce the bass
brushing method and commend patient’s use of
it. Make any necessary modifications based on
the evaluation to ensure effective plaque
removal.
End of
2. Evaluate patient’s flossing technique at each treatment (2-
appointment, and make changes or suggestions 3weeks)
as necessary. Compare baseline bleeding score
with those for the current appointment.
End of
treatment
3. Check the production of the salivary glands.
Perform the “mirror test” against the patient’s
 STG: By the end of the appointment patient will be able to cheeks.
define xerostomia and understand what caused it (in his case).

STG: Patient will take frequent sips of water throughout the

day to help manage his dry mouth.

STG: Mr. Williams will chew xylitol containing gum about 2x

a week to stimulate salivary production and aid in cavity
prevention.

Prognosis Explain your prognosis

Good I think this patient has a fair prognosis. He is taking medication that causes xerostomia, which
Fair increases his risk for caries.. Although he has a good plaque score, brushes for a full 2mns, and
Poor uses the bass technique, he only brushes once a day, and has arthritis, which may reduce his
Questionable dexterous capabilities when removing plaque. He also does not floss, but he does uses his
Hopeless adjunctive aid (waterpik) 3-4x a week. The patient has 4 crowns, which are biofilm retentive
features, and may be great factor in the progression of his periodontitis. He has localized
periodontal pocket depths of 4 and above (7 being the highest). He does have an interest in his
oral care and wants to keep the remaining teeth that he has, however his dental visits are
infrequent.

Appointment Plan

Appt # Plan for Treatment Plan for Education, Counseling or Oral Hygiene Instruction
Medical and dental history with vital signs Gather assessment information to develop treatment plan.
1 Statement of release
Acknowledgement of HIPAA Plan for next appointment
Radiographs – digital BWX
Head and neck exam
Periodontal assessment
 Dental charting
Periodontal disease risk assessment
Plaque and bleeding score
Informed consent
Patient education
2 Update medical and dental history
Patient education
Calculus detection
Scale UR and start UL
Update medical and dental history
3 Patient education
Complete scaling UL and LR
Update medical and dental history
4 Patient education
Scale LL
Polish
Floss
Apply topical fluoride varnish
Referrals: None
Recall Interval: 3-4 months
Define and explain periodontitis using the flipbook, and how to
halt the progression by flossing. Demonstrate flossing both on
typodont and in the patient’s mouth with a hand mirror so
they can see. Then have patient demonstrate in the mirror.
Plan next appointment
Review patient education from last session by asking patient to
define periodontitis and demonstrate proper flossing
technique.
Explain that the patient’s medication can cause xerostomia,
and that xerostomia can increase the risk for cavities. Suggest
ways to increase salivary flow, such as sucking on hard candy,
and the use of Biotene products to help with salivary
production. Educate patient on how fluoride rinses and xylitol
containing products can reduce risk for caries.
Plan next appointment
Review patient education from last session and evaluate
salivary flow.
Give patient post application instructions on fluoride varnish.
Advise against brushing or flossing for 4-6hrs and from
consuming anything hot or crunchy so that the teeth have a
longer exposure time to the fluoride.