Patient Specific Dental Hygiene Care Plan

Patient Name _________________ Age _____ Gender: M F

Student Name _Tara Thompson_______________ Date _4-12-17____

Chief Complaint: Needs cleaning

Assessment Findings

Medical History At Risk For

Describes general health as good/ last physical was in 2016 Unknown
Takes Lisinopril 10mg 1 tab per day------------------------------- Xerostomia,
Takes Bethanechol 25mg

Social and Dental History At Risk For

Tobacco Use for 2 years------------------------------------------------
Smokes 3 cigarettes per day
Has tried to quit smoking in the past, and is interested in
quitting now---------------------------------------------------------------
} Oral cancer, delayed healing, gingivitis/periodontitis

Reason for visit is a cleaning, last cleaning was 2005--------- Gingivitis, periodontitis, caries
Clenches and grinds teeth-------------------------------------------- Attrition, TMJ problems
 Dental Examination At Risk For
Picks at fingernails----------------------------------------------------- Infection
Nose off centered to the right-------------------------------------- None
Scattered ephilids------------------------------------------------------ Skin Cancer
Near-sided---------------------------------------------------------------- Unknown
Bilateral Lymphadenopathy----------------------------------------- Infection/ Cancer
Jaw deviation to the left/ lock jaw---------------------------------- TMJ
Tori on hard palate------------------------------------------------------ Ulcers, over growth, interfering with speech
Linea Alba---------------------------------------------------------------- Unknown
Clenching/grinding--------------------------------------------------- Attrition, TMJ problems

Soft Tissue:
Slight Generalized biofilm--------------------------------------------
Color: Red on max and mand lingual-------------------------------
Texture: Smooth and shiny--------------------------------------------
Shape of papilla: Bulbous---------------------------------------------
Pocket Depths: 4s in posterior------------------------------------
Generalized bleeding points----------------------------------------
Caries, periodontitis, gingivitis
}Gingivitis/inflammation, periodontitis
Gingivitis, periodontitis, inflammation, infection
Gingivitis/ periodontitis
Gingivitis, periodontitis, inflammation

Periodontal Case Type: 1 Plaque Score: _1.6 good____ Bleeding Score: _16%____

Gingival Inflammation: Generalized papillary and marginal

Biofilm: Slight Generalized
Biofilm Retentive Features/Predisposing Factors: Calculus, malpositioned teeth, smoking
 Dental Hygiene Diagnosis

Problem Related to Risk Factors or Etiology

Plaque----------------------------------------------------------------------- Poor Home Care

Gingivitis-------------------------------------------------------------------- Poor Home Care/ Inflammation
Exposure to carcinogens/ habit
Smoking---------------------------------------------------------------------
 Planned Interventions

Clinical Education Oral Hygiene Instruction

Plaque- white sticky substance that forms on the Brushing, flossing, regular cleanings to reduce
Scaling hard deposit teeth. It can be removed by brushing, flossing plaque.
removal and mouth rinses. It causes gingivitis,
periodontitis, and caries.

Polishing soft deposit Gingivitis- It is reversible inflammation of the Brushing, flossing, mouth rinses.
removal gingiva. It can be halted by brushing and flossing.
If the gingivitis is not halted it can lead to
periodontitis/ bone loss.

Fluoride application Smoking- increases risk of developing Brushing, flossing, regular oral cancer screenings.
periodontitis. Periodontitis is irreversible but can
be halted. Educate patient on oral
cancer/lesions.
 Expected Outcomes

Goals Evaluation Method Time Frame

6 months
LTG 1: Reduce plaque score to 1.3 1. Watch patient brush, and evaluate
plaque score
STG: Define Plaque
STG: Demonstrate correct brushing technique
STG: Reduce plaque score by .1 each visirt
2. Watch patient floss, evaluate gingiva 6 months
LTG 2: Halt gingivitis
STG: Define gingivitis
STG: Correctly demonstrate brushing and flossing
STG: Reduce gingival inflammation
3. Watch patient do a self-oral cancer 6 months
LTG 3: Tobacco cessation
screening
STG: Define oral cancer
STG: Teach patient oral cancer screenings
STG: Reduce smoking habit to 4 cigarettes per week

Prognosis Explain your prognosis

Good is a good patient; She is engaged and eager about treatment plan.
Fair
Poor
Questionable
Hopeless
 Appointment Plan

Appt # Plan for Treatment Plan for Education, Counseling or Oral Hygiene Instruction
Perio debridement on UR X Reduce plaque score by brushing in the morning and at night
1 quadrant. Check plaque score and using the bass method.
bleeding score.

Reverse gingivitis by proper brushing and flossing techniques.

2 Perio debridement on LR
quadrant. Check plaque score and
bleeding score.
X

Proper oral hygiene- brushing, flossing, mouth rinses.

3 Perio debridement on LL
quadrant. Check plaque score and
bleeding score. X

Home care- brushing, flossing, mouth rinses, oral cancer

4 Perio Debridement on UL screenings.
quadrant. Check plaque score
and bleeding score
X

Referrals: None
Recall Interval: 6 months