Patient Specific Dental Hygiene Care Plan

Patient Name Age 19 Gender: M F

Student Name Jorden Prewitt Date 3/28/17

Chief Complaint: Needs cleaning, Whiten teeth

Assessment Findings

Medical History At Risk For

Last physical July 2016------------------------------------------Unknown pathologies or health risks

Surgery Thumb reconstruction-----------------------------Arthritis

Collapsed lung----------------------------------------------------- Impaired or irregular breathing

Heart Murmur 2014 had since childhood pt claims no

concern-------------------------------------------------------------- Heart complications, irregular heart beat

Penicillin Allergy as child (6yrs old)------------------------ Anaphylaxis (rxn face swells, body swelling)
 Social and Dental History At Risk For
Used Tobacco Products for 4+ years------------------------- Oral and lung cancer

Uses one half pack per day------------------------------------- Oral and lung cancer

Has previously attempted to quit multiple times-------- Relapse or reoccurrence of tobacco use

Drinks alcoholic beverages------------------------------------ Carries

Needs cleaning----------------------------------------------------- Carries, gingivitis

Last dental cleaning was 2 yrs ago -------------------------- Carries, gingivitis

Clenches ------------------------------------------------------------ TMJ complications

Pt drinks sugary drinks 2-3 per week----------------------- Carries, gingivitis

Dental Examination At Risk For

Mesonathic--------------------------------------------------------- none

Skin tissue: 4 scattered nevi on rt cheek and chin 2x2

darker brown developmental, 1 nevi lt chin 2x2 darker
brown developmental ------------------------------------------ Skin cancer

1 nevi 2x2 rt eyebrow above inner canthus from reg, lt

brown developmental------------------------------------------- Skin Cancer

Glasses does not wear them (astigmatism)---------------- Blindness, visual impairment

Small mandibular tori Lt --------------------------------------- Growth & interference with speech and eating
Tissue trauma Rt posterior Lateral boarder of tongue
(self inflicted) ----------------------------------------------------- Infection

Grinding, generalized- anterior------------------------------ Attrition, TMJ complications

Clenching------------------------------------------------------------ TMJ complication

Mouth breathing -------------------------------------------------- Biofilm build up, carries?

Occlusion:

Molar: Rt 1 Lt- Unclassifiable ------------------------------- None

Canine: Rt Tendency to 3 Lt 1 tendency to 2--------- None

Overbite: 4mm----------------------------------------------------- TMJ Complications

Overjet: 1mm------------------------------------------------------- None WNL

Midline shift 2mm to lt ------------------------------------------ TMJ Complications

Generalized Moderate Biofilm (Malpositioned teeth

tobacco use)-------------------------------------------------------- Carries, staining, gingivitis, Perio
Bulbous papillae Man Ant 8 & 9 Facial --------------------- Gingivitis, perio
Margins Rolled- Loc- man canines & Premolars --------- Gingivitis, perio
Recession Man. & Max Canines, Loc. Man Lt. Ant ------ Root sensitivity, gingival loss, perio

Pocket depts- 4 mm Generalized Man & Rt Max

Posterior ----------------------------------------------------------- Recession, periodontitis
Bleeding- Generalized ------------------------------------------ Gingivitis, periodontitis

Horizontal Bone Loss UL Between 13 &14 ---------------- Periodontitis

Calculus UR UL LL LR generalized posterior ------------------ Gingivitis, perio
Impacted tooth #20 ---------------------------------------------- Pain, inflammation, infection

Periodontal Case Type: Case 2 Plaque Score: 2.5 Fair Bleeding Score: 14.2%

Gingival Inflammation: Generalized, Papillary

Biofilm: Moderate, Generalized
Biofilm Retentive Features/Predisposing Factors: Calculus, malpositioned teeth, tobacco use.
 Dental Hygiene Diagnosis

Problem Etiology

Plaque---------------------------------------------------------------- Inadequate home care

Gingivitis------------------------------------------------------------ Poor brushing habits/ home care, inflammation, bacteria
Tobacco use -------------------------------------------------------- Self choice

Planned Interventions

Clinical Education Oral Hygiene Instruction

Scaling hard deposit Plaque ----------------------------------------------- Teach patient what plaque is and teach tooth
removal brushing technique chair side

Gingivitis -------------------------------------------- Teach gingivitis and flossing techniques

chair side and that the progression of
Polishing soft deposit gingivitis can lead to periodontal disease
removal

Tobacco use-----------------------------------------
Teach the importance of tobacco cessation
Fluoride application and elaborate on some of the things that may
occur if there is continued use (ex. Staining,
oral cancer, gingivitis..)
 Expected Outcomes

Goals Evaluation Method Time Frame

LTG 1: Patient will reduce the bacteria in his mouth and 1. At each appointment disclose and watch pt
maintain a low plaque score. brush and evaluate plaque score. Plan to have
patient improve score by .5 each appointment.
STG: Patient will define plaque and use a disclosing LTG:
End goal being within the good percentile.
solution to detect plaque in his mouth by (3/26/2017). 6months
STG: Patient will correctly demonstrate sulcular brushing STG:
in his mouth and flossing by (3/26/2017).
2 weeks
STG: Patient will lower his plaque score at each
appointment.

LTG 2: Patient will achieve healthy gingival tissues as

shown by an improved soft tissue description and a
bleeding score of less than 5% by (4/17/2017).

STG: Patient will explain how plaque causes gingivitis by
(4/17/2017).
STG: Patient will decrease his bleeding percentage by
.01% at every appointment until .05% or less is
maintained.
STG: Patient will correctly demonstrate flossing. Pt will
attempt flossing 2x per week.
2. At each appointment have pt floss and
evaluation bleeding score. Plan to have patient
reduce bleeding score by at least 1.5 points
each appointment. End goal being below 4. By
using a C shape flossing method 2x per week. LTG:
6 Months
STG:

2 Weeks
 LTG:

LTG 3: Patient will terminate all tobacco use by (4/17/18) 3. Have the patient reflect back the potential 1 year
risks of tobacco use. Watch the patient give self-
STG: Patient will understand the potential occurrence of
intra/extra oral exam and correct or modify to
oral and lung cancer due to tobacco use by (4/17/17)
fit needs. Confirm with patient that he has STG:
STG: Patient will understand how to do self intra/extra either or both called the 1-800 hotline and or
scheduled a doctors appointment to receive 2 Weeks
oral exam (4/17/2017)
medical tobacco cessation help.
STG: Patient will receive pamphlet with 1-800 hotline for
tobacco cessation and make an appointment with doctor to
receive medical help with cessation by (4/17/17)

Prognosis Explain your prognosis

Good

Fair During chair side education, patient seemed to be genuinely interested in brushing
technique. Patient did express a distasted towards brushing but had a well response in
Poor understanding its importance. Patient also showed and general understanding of the
Questionable importance of tobacco cessation but expressed minimal interest in quitting tobacco
use. Patient is fair.
Hopeless
 Appointment Plan

Appt Plan for Treatment Plan for Education, Counseling or Oral Hygiene
# Instruction
Teach plaque and Brushing
1
Med/Den Hx Evaluate pt brushing technique, teach sulcular
brushing method and ask to implement 2x per
Head/Neck/Intra Exam day, define plaque
Perio Assessment Give chair side Ed on how to reduce teeth
sensitivity (Fluoride OTC based tooth pastes &
Plaque Score rinses)

Dental Chart

Informed Consent

Teach Gingivitis and Flossing

2
Educate Pt on plaque due to poor plaque score.
Reteach patient sulcular Brushing Technique
Scale Max Rt & Lt
Implement sulcular brushing into home care

Work on Brushing and Flossing

3
Scale Man Rt & Lt Educate Pt on Gingivitis due to having gingival
inflammation
Teach patient Flossing
Have patient implement into home care atleast
twice per week
 Teach Tobacco Cessation
4
Plaque free Educate Pt on tobacco cessation.
Give patient pamphlet with 1-800 hotline and
Polishing
encourage pt to schedule an appt with MD to
Fluoride Treatment receive medical help.
Teach patient the importance of tobacco
cessation

Referrals: None
Recall Interval: 6 months