Patient Specific Dental Hygiene Care Plan

Patient Name: Patient Age:74 Gender: F

Student Name: Tori Touchet Date: April 9, 2017

Chief Complaint: Routine cleaning

Assessment Findings

Medical History At Risk, For

Last physical June 2016------------------------- None
Prescription and nonprescription medications--- Adverse reactions
Herbal medications------------------------------ Adverse reactions
Surgeries include: Gallbladder 2000, tonsils 1974, breast Possible future complications from the surgical procedures, she
tumors 15 years old, tumor in gums (endodontist) 2008, and currently has no complications.
cataracts 2010 Back pain and patient discomfort in chair
Arthritis (in back) patient goes to the chiropractor--------------- Facial pain, pressure, congestion, cough, fever, cold, and flu
Sinus problems(seasonal)-------------------------------------------------- Goiter, heart failure, depression, and coma
----- Blindness
Cold sores can be painful and itch
Hypothyroid disease (patient is seeing doctor and on Hives, itching, stuffy or runny nose, asthma, wheezing, chest tightness,
medication)------------------------------ and difficulty breathing
Glaucoma (seeing eye doctor)-------------------------------------------
Herpes/cold sores (occasionally)------------------------------------
Allergic to latex (patient gets rash)--------------------------------------
-----
 Social and Dental History At Risk For

Last dental visit was December 2016 with an FMX --------- None, she keeps up with regular dental appts.

Xerostomia-------------------------------------------------------- Gingivitis, infection, high bacteria count, dental caries, and periodontal
disease
Drinks 1 diet coke per day------------------------------------------------ High bacteria count, dental caries, and infection

Dental Examination At Risk For

Mesognathic--------------------------------------------------------------- None
Scattered Ephelids on forearm and hands----------------------- Skin cancer
Macules-------------- Skin cancer
Papules ----------------------------------------------------- Skin cancer
Grinding ------------------------------ TMJ pain and soreness, headaches, attrition, broken teeth

Occlusion unclassified on the right side(molar), class 1 for the Mal-positioned teeth, jaw pain, broken teeth, esthetics
right canine, unclassified on the left side(molar), class 1 for
the left canine, over bite-1mm, overjet-1mm, cross bite on #4, None
and midline shift 1mm right--------------------------- None
None
Generalized healthy scalloped pink gum tissue --------------------- Gingivitis and periodontitis
---------- Periodontitis and root caries
Smooth surface texture papillary and marginal--------------------- None
----------- None
Stippled surface texture attached--------------------------------------- Periodontitis
---------
Generalized rolled margins------------------------------------------------
--------
Recession on #s 4,6,7,14,19,20,29,31----------------------------------
--------------------------
Pocket Depths WNL ---------------------------------------------------------
---------
No suppuration-----------------------------------------------------------
Generalized mild horizontal bone loss UR, UL, LL, LA--------------
---------------------

Periodontal Case Type: Case 2 Plaque Score: 1.2 Bleeding Score: 0%

Gingival Inflammation: None

Biofilm: Slight generalized
Biofilm Retentive Features/Predisposing Factors: None
Predisposing factors: Medications

Dental Hygiene Diagnosis

Problem Related to Risk Factors or Etiology

Plaque/Calculus-------------------------------------------------------------- Environmental factors, bacteria, homecare, retentive features

---------

Plaque accumulation, home care, host response

Periodontitis ----------------------------------------------------------------- Progression of bone loss around the missing teeth, supraeruption of
--------- opposing teeth

Missing teeth---------------------------------------------------------------
 Planned Interventions

Clinical Education Oral Hygiene Instruction

Plaque----------------------------------------------------- Define plaque and use flipbook page on plaque to tech the
Scaling hard deposit patient how plaque is contributing to their current
demineralization and past caries. Discuss the plaque score,
removal teach and show the patient ways to reduce the plaque
score by the next visit. Teach Bass method of brushing and
Polishing soft deposit have the patient demonstrate in the mirror what they have
removal learned in the session.

Fluoride application

Periodontal disease------------------------------------
Start the session by having the patient define plaque and
review the brushing technique that we learned at the last
session. Ask the patient how they are doing with the Bass
method of brushing and have them show you again, make
any changes needed. Define and explain periodontal
disease and use the patients x-rays to show bone loss, use
the flipbook page to show the progression of the disease.
Teach flossing technique using the typodont and flipbook
page. Have the patient demonstrate the flossing teaching
in the mirror.

Start the session by reviewing the brushing and flossing

techniques that we learned in the last two sessions. Ask
Tooth loss and dental implants--------------------- the patient how they are doing with the new techniques,
watch them demonstrate and make any changes needed.
 Use the patients x-rays to show bone loss in the area of
the missing teeth and use flipbook page about implants to
educate the patient about how implants can help maintain
her bone level. Teach the patient about how all the
techniques he has learned will help stop the progression of
her periodontal disease.

Expected Outcomes

Goals Evaluation Method Time Frame

3 weeks
LTG 1: Patient will reduce the bacteria count in her mouth 1. Plaque score evaluation at every visit
by maintaining a lower plaque score than her current score using the disclosing solution. Teach the
of 1.2. bass method of brushing and have the
patient demonstrate this method at
STG: Patient will be able to define plaque and use
every visit and make any changes needed
disclosing solution to detect plaque by her second visit.
for more effective plaque removal.
STG: Patient will learn the Bass method and be able to
demonstrate this proper brushing technique by second visit.
STG: Patient will lower her plaque score by 0.3 in 3 weeks.
LTG 2: Patient will stop the progression of her periodontal
disease using the techniques she will learn in patient
education. 2. Plaque score evaluation and have the
6 months
STG: Patient will be able to define periodontal disease and patient demonstrate the bass method of
understand how the disease can progress. brushing that he learned at the last visit.
Make any changes necessary to improve
STG: Patient will be able to demonstrate proper flossing
the brushing method. Teach flossing
technique and understand why flossing will help stop the
method and evaluate this at every visit.
progression of her bone loss and periodontal disease.
Take Bitewing x-rays in 6 months to
STG: Patient will stop the progression of bone loss and check bone levels.
periodontal disease by the 6-month recall visit.
LTG 3: Patient will consider dental implants to replace
missing teeth and maintain bone levels.
 STG: Patient will be able to understand how implants can
help maintain her bone levels.
STG: Patient will have a consultation with her dentist to
see if she is eligible for implants.
STG: Patient will make an appt. with an oral surgeon or
implant specialist to get pricing information on implants.
3. Take bitewing and panoramic x-rays to
evaluate the patients bone levels. Ask
1 year
questions about how her dental visits
went and if she was a candidate for
dental implants.

Prognosis Explain your prognosis

Good I believe Patient has a good prognosis. She is very concerned about her oral and overall health
Fair and I believe she will take the steps needed to stop the progression of her periodontal disease.
Poor She is very receptive and seems like she wants to learn more about her oral health.
Questionable
Hopeless

Appointment Plan

Appt # Plan for Treatment Plan for Education, Counseling or Oral Hygiene Instruction
Define plaque and use flipbook page on plaque to tech the patient how
1 Medical and dental history with vital signs plaque is contributing to their periodontal disease and demineralization.
Pre-rinse Discuss the plaque score, teach and show the patient ways to reduce the
Plaque score plaque score by the next visit.
Begin periodontal debridement
Scale upper right and lower right Teach Bass method of brushing and have the patient demonstrate in the
Patient Education session #1 mirror what they have learned in the session.

Plan next appointment

Start the session by having the patient define plaque and review the
2 Review medical and dental history brushing technique that we learned at the last session.
Pre rinse Ask the patient how they are doing with the Bass method of brushing
Plaque Sore and have them show you again, make any changes needed.
Continue periodontal debridement on upper left and
 lower left Define and explain periodontal disease using the patients x-rays and
Patient Education session #2 flipbook page. Teach the patient how to stop the progression of
periodontal disease by teaching flossing technique using the typodont
and flipbook page. Have the patient demonstrate the flossing teaching in
the mirror.
Plan next appointment

Review medical and dental history Start the session by having the patient demonstrate the bass method of
3 Pre rinse brushing and the flossing technique we learned in the last two sessions
Plaque score Use the patients x-rays and flip book page to educate the patient about
Polish (plaque free) dental implants.
Floss
Apply Fluoride varnish Use the patients x-rays to show her where her bone loss is located. Talk
Patient Education session #3 to the patient about implants can help maintain her bone levels and ask
her if she would be willing to talk with her dentist about implants to
have them evaluate and see if she is a candidate for implants.

Schedule 4-6-month recall visit

Referrals: Refer to DDS for evaluation about implants

Recall Interval: Every 4-6 months