Date: April 5th 2019 DMACC

Student Name: Danielle Teachout Dental Hygiene

Patient Name: William A,
DOB: 11/30/1981
Medical History & Medications:
No history of past medical problems. No
current medications. Patient is not
currently under the care of a physcian.
Developmental Abnormalities &
Defects:
None
Treatment Plan
ASA Physical Status
Classification:
ASA I
Restorative Problems:
Suspicious decay 1, Class IV
decay on 7,8,10,15, and 21
Dental History: Occlusion:
Active decay, No history of restoration Unilateral posterior cross bite,
Class II
Other: Radiographic Evidence:
      Exposed FMS and Pano on
4/18/2019 at DMACC. Dr.
Allison reviewed and confirmed
decay on 7,8,10,15,21. Dr.
Allison reffered patient to have
#1 extracted. Radiographic
calculus detected on 23-26.

Risk Factors are as follows (be specific).

1. Systemic Health: Good 3. Caries 4 active decay locations
confirmed by DDS Dr. Allison
CVD: No Sugar Intake: High
Diabetes Mellitus: No Streptococcus Mutans Count: N/A
Respiratory Disease: No Plaque-Removal Ability: Able to use toothbrush. Patient
does not floss. Patient states can
not floss lower anteriors due to
not being able to fit floss between
#24 and #25
Osteoporosis: No Socioeconomic Status: Middle Working Class
Preterm Low Birth Weight: No Plaque Retentive Factors: Mandibular anterior crowding
making it difficult for cleaning.
Behavioral Status: Good Fluoride History: Fluoride water in the home while
growing up. No dental treatments
at a home Dentist .
Psychosocial Status: Dental Anxiety Past & Present Caries Activity: No past restorations, Several
areas of rampant decay.
Medication Considerations: Not currently taking Other: None
medication

1
 Other:      
4. Periodontal Disease: Generalized Moderate, No sites
of bleeding
2. Oral & Pharyngeal Cancer: None (host environmental risk factors/indicators)
Tobacco Use: Patient currently smoking Previous History of Disease: Patinet is aware the current state
Cigarettes - 1 pack a day. of their teeth but has not been to
Patient also occasionally uses a home DDS is several years.
a nicotene vape
Race: Caucasian Classification of Disease(s): Gen Mod
Alcohol Use Patient consumes 4+ alcoholic Clinical Attachment Loss: Areas 6 and 7 mm pockets
beverages on the weekends
Sun Exposure: Patient holds a career is home Stress Factors
construction and spends 12
hours a day in the sun during
the summer months.
Pathology: Nicotine Stomotitis PHP: 2- Fair
Other:       PBI: 0- Health
Deposits Classification: Class V
Bacterial Pathogens: s. mutans and p. gingivalis
Tobacco Use: Patient currently smokes
cigarettes and also uses a
nicotine vape
Glycemic Control N/A
Inherited Risk HIGH
Other:      

2
Date: April 5th 2019
Student Name: Danielle Teachout
Patient Name: William Anthony Agan
DOB: 11/30/1981

Diagnostic Decision Making

Eight Human Needs Related to Oral Health & Disease
Assessment (check signs and symptoms present)
1. Wholesome Facial Image 5. Freedom from Head and Neck Pain
Teeth Gingiva Facial Profile Extra-/intra-oral pain or sensitivity
Breath Other:       Other:

2. Freedom from Anxiety/Stress 6. Biologically Sound & Functional Dentition

Reports or Displays: Reports difficulty in chewing
Anxiety about proximity of clinician confidentiality or previous Presents with:
dental experience. Defective restorations Ill-fitting dentures, appliances
Oral Habits Substance Abuse Teeth with signs of disease Abrasion erosion
Missing teeth Rampant caries
Concern about: Other:     
Infection control, fluoride therapy, fluoridation, mercury toxicity

3. Skin & Muccous Membrane Integrity of Head & Neck 7. Responsibility for Oral Health
Extra/intra-oral lesion Pockets greater than 4mm Plaque and calculus present
Swelling Attachment loss greater than Inadequate parental supervision of oral health care
4mm No dental exam within the last 2 years
Gingival inflammation Xerostomia Other:      
Bleeding on probing Other:      

4. Protection from Health Risks 8. Conceptualization & Understanding

BP outside of normal limits Need for prophylactic antibiotics Has questions about DH care and/or oral disease
Potential for injury Risk Factors Other:      
Other:      
3
Date: April 5th 2019
Student Name: Danielle Teachout
Patient Name: William Anthony Agan
DOB: 11/30/1981

1. Initial Review Statement (chief concern, patient wants and expectations):

My patient’s chief complaint is the image of his teeth. The patient is aware that his teeth are bad. My patient believes that he cannot smile while
meeting with his clients of his construction company. He would like to be able to smile and not feel self-conscious about his teeth. He is aware that
he has some teeth that need to be extracted due to heavy decay. Patient wants to keep his original teeth. Patient states that some of his family
members wear dentures and does not want the same outcome. Currently my patient does not have a home dentist. He has not seen a dentist in almost
15 to 20 years. My patient does have a past experience with drug use. Patient believes that the decay on his anterior teeth appeared after his sobriety.
He is currently not taking any medication. He is a current tobacco smoker with the interest is quitting. Because it has been years since my patient has
seen a dentist he presented with heavy calculus. My patient is aware that he will require a full scaling and root planning. Because he has radiographic
calculus and horizontal bone loss he is aware that he will require local anesthesia. He is anxious about starting treatment and is in agreement that
nitrous oxide will be used during his first appointment. My patient also is aware that to maintain his attachment level he will require multiple recall
visits every 3 months.

2. Hypotheses (differential diagnosis):

Poor home care
No dental home
No dental or medical insurance
Prior methamphetamine use
Heavy plaque
Radiographic calculus
Rampant decay
Lack of knowledge of etiology of periodontitis and dental cavities
Generalized Moderate Periodontitis
Insufficient interproximal cleaning

3. Inquiry Strategy:
Review patients health history
Extraoral head and neck exam
Intraoral exam
PBI
Calculus detection
PHP
Full mouth radiographs
4
Pano radiograph to review all remaining third molars
Intra oral photographs
CAMBRA assessment
Scaling and Root Planning
Patient education on the effects of previous methamphetamine use
Patient education on flossing
Patient education on alternative interproximal care- proxy brush
Education of possiable procedure for tooth extractions
Education of possiable procedure for composite restorations
Education of periodontal disease
Education of tobacco usage
Educate pt on chewing xylitol gum after meals
Education of needed 3 month SPMs
Recommendation for electric toothbrush
Nutritional counseling
Referral to Oral surgeon
Referral to home Dentist

5
Date: April 5th 2019
Student Name: Danielle Teachout
Patient Name: William A.
DOB: 11/30/1981
4. Dental Hygiene Diagnosis (list the human need not met, then be specific about the etiology & signs & symptoms evidencing a defect) :
Unmet Human Need
Wholesome Facial Image-Teeth
Wholesome Facial Image- Gingiva
Wholesome Facial Image- Facial Image
Wholesome Facial Image- Breath
Freedom from Stress and Anxiety-Previous
Dental Experience
Freedom from Stress and Anxiety- Substance
Abuse
Skin and Mucous Membrane Integrity of Head
and Neck-Extra/Intra-oral lesion
Skin and Mucous Membrane Integrity of Head
and Neck-Gingival inflammation
Skin and Mucous Membrane Integrity of Head
and Neck-Pockets greater than 4mm
Skin and Mucous Membrane Integrity of Head
and Neck-Attachment loss greater than 4mm
Etiology Signs & Symptoms
Prior drug use Pt complains of large dark areas on front teeth
High sugar content diet making him unable to smile.
Lack of regular home DDS
Lack of interproximal cleaning
Lack of regular dental cleanings Gingival recession on over 30% of his teeth
Lack of interproximal cleaning
Lack of homecare cleaning
Lack of knowledge of cleaning
Mesial shift Mandibular anterior crowding
No previous orthodontics
Peridontal disease Strong halitosis Experienced during assessment
Lack of TB before appointment
Traumatic extraction of roots of third molar Pt complains of prior Traumatic experience
during the extraction of 32
Health history Pt is a previous Methamphetamine user
Lack of knowledge of drug use on the teeth
Low income/homeless
Tobacco smoker for many years Pt presents with nicotine stomatitis
Hot coffee drinker
Ineffective toothbrushing Bright red and swollen gingiva
lack of interproximal cleaning
lack of dental knowledge
lack of professional dental care
Lack of interproximal cleaning Deep pocket depths around #2,15,17,31
lack of dental knowledge
poor toothbrushing techniques
irritation from plaque and calculus
Lack of interproximal cleaning Recession around more than 30% of his teeth
lack of dental knowledge
6

Freedom from Head and Neck Pain-intra oral
sensitivity
Biological Sound & Functional Dentition- Teeth
with signs of disease
Biological Sound & Functional Dentition-
Abrasion erosion
Biological Sound & Functional Dentition-
Rampant caries
Responsibility for Oral Health- Plaque and
Calculus present
Responsibility for Oral Health- No dental exam
within the last 2 years
poor toothbrushing techniques
irritation from plaque and calculus
Heavy on molars with exposed pulp canals Pt reports sensitivy to cold, hot and sweets toward
the back of the mouth
Lack of interproximal cleaning Large dark lesions on anterior teeth. #1 crown
lack of dental knowledge dark and no longer present in the mouth. #16
poor toothbrushing techniques hollow crown
irritation from plaque and calculus
Prior drug use
High sugar content diet
Prior drug use Dark areas around mandibular molars
GERD
Acid reflux
Lack of interproximal cleaning Large amout of dark areas of visible decay
lack of dental knowledge
poor toothbrushing techniques
irritation from plaque and calculus
Prior drug use
High sugar content diet
Ineffective toothbrushing Heavy supragingival calculus on mandibular
lack of interproximal cleaning anterior teeth
lack of dental knowledge
lack of professional dental care
Lack of dental insurance Review of health history where pt reports has not
Lack of income seen a DDS in 15+ years
Lack of dental knowledge

Conceptualization & Understanding- Has Lack of dental knowledge Pt asks many questions about xrays, procedure of
questions about DH care and/or oral disease Low education status dental cleaning, and how often normal cleanings
Low income take place.
                 
                 
                 
                 
                 
                 
                 

7
8
 Jointly Determined Treatment Plan
Date: April 5th 2019
Student Name: Danielle Teachout
Patient Name: William Anthony Agan
DOB: 11/30/1981
Patient Goals Educations and Treatment Evaluation
(Target etiologies) (goal met, partially met or unmet)

9
Apt #: 1- New Patient Assessment
Date: April 5th 2019
Time Req: 4 hours
1) Pt will consent to treatment. 1. Obtain pt consent for 1. Patient consents to
2) Pt will provide a treatment. Have Pt sign and date treatment- Goal met
comprehensive health history, consent to treat form and record on 2. Patient provided full health
including health conditions, chart. history- Goal met
allergies, medications. 2. Review patient’s health 3. Patient provided full dental
3) Pt will provide a dental history informing the patient why it history- Goal met
history including past appointments, is important to have a current and 4. Patient agrees with
Past radiographs taken and any full completed health history importance of vital signs- Goal met
anxieties toward his appointment. 3. Review dental history, 5. Patient placed arm out and
4) Pt will show understanding including past appointments and consented to having vital signs
of importance of checking vital signs previous radiographs taken- Goal met
before appointment. 4. Explain to patient purpose of 6. Patient explains chief
5) Pt will consent to having checking vital signs prior to complaint- Goal met
blood pressure and pulse taken treatment. 7. Patient shows understanding
before appointment. 5. Measure blood pressure and of CHX rinse- Goal met
6) Pt will report his chief pulse and record on pt chart. BP in 8. Patient washes with CHX
complaint normal range rinse- Goal met
7) Pt will understand 6. Ask the patient to explain if 9. Patient agrees to wear
importance of CHX rinse they have a chief complaint and napkin. Patient places on safety
8) Pt will consent to CHX rinse record on patients chart. glasses- Goal met
9) Pt will consent to wear the 7. Explain to patient the 10. Patient showed
patient napkin and eye protection purpose of CHX rinse. Give understanding of EIE exam. Patient
10) Pt will consent to EIE exam. direction of CHX rinse. give consent- Goal met
11) Pt will understand findings 8. Obtain patient consent for 11. Patient understands EIE
of EIE exam. CHX rinse. Record in patients chart findings- Goal met
12) Pt will consent to dental 9. Explain the importance of 12. Patient understands hard
charting eyewear and pt napkin and provide tissue findings- Goal met
13) Pt will understand them to pt. 13. Patient understands purpose
importance of a full mouth probe 10. Explain purpose of EIE exam of full mouth probe- Goal met
evaluation and consent and obtain consent to preform exam 14. Patient understands what is
14) Pt will show understanding 11. Explain any EIE findings; normal pocket depth. Patient
of probing depths Chart and findings understands their current pocket
15) Pt will show understanding 12. Explain purpose of hard dept- Goal met
of PBI score. tissue charting. Obtain consent; 15. Patient understands their PBI
16) Pt will understand purpose of Chart any findings score. Patient understands the
disclosing solution 13. Explain purpose and meaning of gingivitis and possiable
17) Pt will consent to disclosing importance of full mouth probe periodontal disease- Goal met
test 14. Explain to patient the 16. Patient understanding
18) Pt will observe disclosed meaning of the pocket depth; disclosing agent- Goal met
10
areas in hand mirror
19) Pt will understand PHP score
20) Pt will discuss homecare
routine he is currently using
21) Pt will understand
recommendation to close mouth
slightly while stretching the cheek to
reach distal of molars
22) Pt will understand
recommendation to brush gently
with soft toothbrush twice a day to
remove food debris and plaque
accumulation.
23) Pt will demonstrate reaching
distal molars with toothbrush while
using the hand mirror
24) Pt will understand purpose
the term calculus and its
contributions to periodontal disease
and gingivitis
25) Pt will consent to full mouth
explore
26) Pt will understand meaning
of deposit classification score.
27) Pt will understand
importance of radiographs and will
consent to a full mouth series.
28) Pt will understand purpose of
lead apron
29) Pt will consent to lead apron
30) Pt will understand the
doctor's diagnosis of
radiographically calculus and bone
loss.
31) Pt will understand the
diagnosis of periodontal disease and
heavy calculus
32) Pt will understand and
consider all options for treatment
11
compare what is normal and what
pockets are in a diseased state
15. Explain PBI results and what
it means. Explain to patient about
gingivitis and the progression to
periodontal disease
16. Explain purpose of
disclosing solution
17. Obtain consent and perform
PHP test
18. Have patient observe
disclosed areas with hand mirror
19. Explain PHP score and
record in patients’ chart
20. Ask patient to describe
homecare routine
21. Recommend patient close
mouth slightly while brushing distal
molars. Demo’d to patient
22. Recommend patient brush
daily with electric TB to remove
plaque build up.
23. Had patient show the TB
technique with hand mirror
24. Explain to patient what
Calculus is and why it is important
to clean off teeth
25. Explain to patient that
calculus will build on anything in
the mouth. Show patient the explore
used to locate the calculus
26. Explain to patient different
calculus scores possiable. Inform the
patient what current calculus score is
27. Explain importance of
radiographs and obtain consent for
full mouth series
28. Explain to patient the
purpose of the lead apron
17. Patient consents to PHP test-
Goal met
18. Patient uses hand mirror to
view areas that have disclosed- Goal
met
19. Patient understands how we
reached current PHP score- Goal
met
20. Patient describes current
homecare- Goal Met
21. Patient uses hand mirror
while showing how stretch the
cheek- Goal met
22. Patient understands using an
electric toothbrush will help oral
hygiene care- Goal met
23. Patient uses toothbrush to
show proper toothbrush technique-
Goal met
24. Patient understands what
calculus is and why regular
cleanings are important for oral
care- Goal met
25. Patient understands that
calculus will build all around the
mouth. Patient will see the explore.
Patient will consent to calculus
detection- Goal met
26. Patient understands current
calculus score- Goal met
27. Patient consents to full
mouth series- Goal met
28. Patient understands the
important of lead apron- Goal met
29. Patient agrees to wear lead
apron- Goal met
30. Patient views radiographs
looking at where the normal bone
level is and where it shows on the
 and what will happen without
treatment., number of appointments,
costs included
33) Pt will understand the
diagnosis of decay and prognosis
with or without treatment
34) Pt will agree to receive SRP
treatment in quadrants, have a 6-
week re eval and maintain
maintenance appointments every 3
months.
35) Pt will agree to find a dental
home and address the teeth with
rampant decay.    prognosis with or without treatment.
36) Pt will understand the
importance of intra oral
photographs  not having them treated
37) Pt will conset to intraoral
photographs
38) Pt will make appointment for
first quad of SRP  eval and maintain SPM appts every
29. Provide patient with
protective lead apron, exposed FMX
radiographs
30. Obtain doctor's evaluation of
the radiographs. Show patient the
radiographs explaining bone loss
calculus build up.
31. Explain diagnosis of
gingivitis and periodontal disease.
32. Explain treatment options for
treatment, Explain what will happen
without treatment, number of
appointments, costs associated and
33. Explain the diagnosis of
dental caries; Explain prognosis of
34. Obtain patients consent for
SRP in 4 quadrants with 4 different
appointments, return for 6 week re
3 months.
35. Explain importance of
treatment caries along with stiology
of dental decay. Sent refferal home
with patient to a dental home for
treatment and restorations.
36) Explain to Pt the use of
before and after photographs
37) Pt will give conest to take
intraoral photographs, document in
chart
38) Pt will make appointment
with front desk.
radiograph. Patient views calculus
on radiographs- Goal met
31. Patient understands diagnosis
of gingivitis and periodontal disease-
Goal met
32. Patient agrees that treatment
is needed for a full scale and root
planning- Goal met
33. Patient agrees that he needs
to have restorations on active decay-
Goal met
34. Patient consents to future
SRP treatment and makes necessary
appointments- Goal met
35. Patient agrees he will make
necessary appointments with a home
dentist to treat active decay- Goal
met
36) Pt will unserstand the
importance of intra oral
photographs-Goal met
37) Pt gives conset to intra oral
photographs- Goal met
38) Pt schedules to first
appointment of SRP- Goal met

Apt #: 2- SRP UR 1. Pt will consent to treatment. 1. Obtain pt consent for Future goal not met at this time
Date: 11/05/2019 2. Pt will provide a treatment. Have Pt sign and date
Time Req: 4 Hours comprehensive health history, consent to treat form and record on
including health conditions, chart.
12
allergies, medications.
3. Pt will provide a dental
history including past appointments,
Past radiographs taken and any
anxieties toward his appointment.
4. Pt will consent to having
blood pressure and pulse taken
before appointment.
5. Pt will report his chief
complaint
6. Pt will consent to CHX rinse
7. Pt will consent to wear the
patient napkin and eye protection
8. Pt will consent to EIE exam.
9. Pt will understand findings
of EIE exam.
10. Pt will consent to disclosing
test
11. Pt will observe disclosed
areas in hand mirror
12. Pt will understand PHP score
13. Pt will explain his process
using the electric toothbrush
technique since last visit
14. Pt will understand proper use
for electric toothbrush
15. Pt will understand the value
of smoking cessation
16. Pt will understand the
importance for using local anesthetic
during todays cleaning
17. Pt will understand the use of
N2O2 along with side effects and
sensation of N2O2
18. Pt will understand the
importance of monitoring vitals
before, during and after
19. Pt will consent to wearing
pulsometer during the appointment
13
2. Review patient’s health
history informing the patient why it
is important to have a current and
full completed health history
3. Review dental history,
Explained to pt the dangerous
progression of dental decay if not
restored. Referred pt to oral surgeon
for decayed third morals.
4. Measure blood pressure and
pulse and record on pt chart. BP in
normal range
5. Ask the patient to explain if
they have a chief complaint and
record on patients chart.
6. Obtain patient consent for
CHX rinse. Record in patients chart
7. Pt places on safety glasses
and allow to be dressed with pt
napkin
8. Pt consents to preform EIE
exam
9. Explain any EIE findings;
Chart and findings
10. Obtain consent and perform
PHP test
11. Have patient observe
disclosed areas with hand mirror
12. Explain PHP score and
record in patients’ chart
13. Pt will explain current dental
care with new electric tooth brush
14. Taught pt to use the glide
and slide method and not to scrub
while using the electric TB.
15. Explain importance of
smoking cessation along with
negative effects of tobacco
16. Explain to Pt that LA is used
20. Pt will understand the for pain management
importance of using the cavitron 17. Explain to Pt that N202 is for
21. Pt will consent to using the dental anxiety. Explain to pt the
cavitron proper sensations of under nitrous
22. Pt will consent to the 18. Explain to the patient that we
administration of local anesthetic will be taking the patients vitals
23. Pt will consent to N2O2 before and after the N2O2 sedation.
24. Pt will follow directions 19. Obtain pt consent for him to
while admin N2O2 wear the pulsometer during the
25. Pt will follow directions cleaning
while admin Local Anesthetic 20. Explain to Pt the importance
26. Pt will tolerate the switch to and benefits of using the cavitron
full oxygen a. Improved efficiency
27. Pt will tolerate SRP b. Lavage of pocket depth
procedure well 21. Obtain pt consent to use
28. Pt will understand post-op cavitron
directions, including pain 22. Obtain pt consent to
management and hygiene administer local anesthetic
instructions. 23. Pt gives consent to
29. Pt will schedule next SRP administer N2O2
appt.      24. Explain to pt deep breaths
from nose only
25. Explain to pt of a little stick
while administering LA. Advised
patient to remain still
26. Explain to pt that todays
cleaning is over. Explain to pt to
continue to breath full oxygen
through nose
27. Pt provides feelings of
todays cleaning. Observe and write
in pt chart
28. Give patient explanation of
possiable post op pain, explain of
possiable sensitivity. Explain to
patient to keep clean with improved
oral hygiene. Reccoment using CHX
at home.
29. Instruct pt to make next appt
14
 with front desk
Apt #: 3- SRP of UL 1. Pt will consent to treatment. 1. Obtain pt consent for Future goal not met at this time
Date:       2. Pt will provide a treatment. Have Pt sign and date
Time Req: 4 Hour comprehensive health history, consent to treat form and record on
including health conditions, chart.
allergies, medications. 2. Review patient’s health
3. Pt will disclose how last history informing the patient why it
appointment went including feelings is important to have a current and
after appointment. full completed health history
4. Pt will consent to having 3. Pt discloses that past
blood pressure and pulse taken treatment went well and healing
before appointment. properly. Record in chart
5. Pt will report his chief 4. Measure blood pressure and
complaint pulse and record on pt chart. BP in
6. Pt will consent to CHX rinse normal range
7. Pt will consent to wear the 5. Ask the patient to explain if
patient napkin and eye protection they have a chief complaint and
8. Pt will consent to EIE exam. record on patients chart.
9. Pt will understand findings 6. Obtain patient consent for
of EIE exam. CHX rinse. Record in patients chart
10. Pt will consent to disclosing 7. Pt places on safety glasses
test and allow to be dressed with pt
11. Pt will observe disclosed napkin
areas in hand mirror 8. Pt consents to preform EIE
12. Pt will understand PHP score exam
13. Pt will explain his current 9. Explain any EIE findings;
home care of previous quad of SRP Chart and findings
14. Pt will disclose current 10. Obtain consent and perform
tobacco use PHP test
15. Pt will consent to wearing 11. Have patient observe
pulsometer during the appointment disclosed areas with hand mirror
16. Pt will consent to using the 12. Explain PHP score and
cavitron record in patients’ chart
17. Pt will consent to the 13. Educate the pt to focus on
administration of local anesthetic interproximal care with proxy brush.
18. Pt will consent to N2O2 14. Explain importance of
19. Pt will follow directions smoking cessation after SRP
while admin N2O2 15. Obtain pt consent for him to
20. Pt will follow directions wear the pulsometer during the
15
 while admin Local Anesthetic cleaning
21. Pt will tolerate the switch to 16. Obtain pt consent to use
full oxygen cavitron
22. Pt will tolerate SRP 17. Obtain pt consent to
procedure well administer local anesthetic
23. Pt will understand post-op 18. Pt gives consent to
directions, including pain administer N2O2
management and hygiene 19. Explain to pt deep breaths
instructions. from nose only
24. Pt will schedule next SRP 20. Explain to pt of a little stick
appt. while administering LA. Advised
patient to remain still
21. Explain to pt that todays
cleaning is over. Explain to pt to
continue to breath full oxygen
through nose
22. Pt provides feelings of
todays cleaning. Observe and write
in pt chart
23. Give patient explanation of
possiable post op pain, explain of
possiable sensitivity. Explain to
patient to keep clean with improved
oral hygiene
24. Instruct pt to make next appt
with front desk
Apt #: 4-SRP of LR 1. Pt will consent to treatment. 1. Obtain pt consent for Future goal not met at this time
Date:       2. Pt will provide a treatment. Have Pt sign and date
Time Req: 4 Hours comprehensive health history, consent to treat form and record on
including health conditions, chart.
allergies, medications. 2. Review patient’s health
3. Pt will disclose how last history informing the patient why it
appointment went including feelings is important to have a current and
after appointment. full completed health history
4. Pt will consent to having 3. Pt discloses that past
blood pressure and pulse taken treatment went well and healing
before appointment. properly. Record in chart
5. Pt will report his chief 4. Measure blood pressure and
complaint pulse and record on pt chart. BP in
16
6. Pt will consent to CHX rinse normal range
7. Pt will consent to wear the 5. Ask the patient to explain if
patient napkin and eye protection they have a chief complaint and
8. Pt will consent to EIE exam. record on patients chart.
9. Pt will understand findings 6. Obtain patient consent for
of EIE exam. CHX rinse. Record in patients chart
10. Pt will consent to disclosing 7. Pt places on safety glasses
test and allow to be dressed with pt
11. Pt will observe disclosed napkin
areas in hand mirror 8. Pt consents to preform EIE
12. Pt will understand PHP score exam
13. Pt will explain his current 9. Explain any EIE findings;
home care of previous quad of SRP Chart and findings
14. Pt will disclose current 10. Obtain consent and perform
tobacco use PHP test
15. Pt will consent to wearing 11. Have patient observe
pulsometer during the appointment disclosed areas with hand mirror
16. Pt will consent to using the 12. Explain PHP score and
cavitron record in patients’ chart
17. Pt will consent to the 13. Educate the pt to focus on
administration of local anesthetic interproximal care with water pick
18. Pt will consent to N2O2 to clean out pocket depth and food
19. Pt will follow directions impaction.
while admin N2O2 14. Educate patient on the harms
20. Pt will follow directions of smoking cigarettes. Educate my
while admin Local Anesthetic patient of smoking cession products
21. Pt will tolerate the switch to 15. Obtain pt consent for him to
full oxygen wear the pulsometer during the
22. Pt will tolerate SRP cleaning
procedure well 16. Obtain pt consent to use
23. Pt will understand post-op cavitron
directions, including pain 17. Obtain pt consent to
management and hygiene administer local anesthetic
instructions. 18. Pt gives consent to
24. Pt will schedule next SRP administer N2O2
appt. 19. Explain to pt deep breaths
from nose only
20. Explain to pt of a little stick
while administering LA. Advised
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Apt #: 6- SRP of LL 1. Pt will consent to treatment.
Date:       2. Pt will provide a
Time Req: 4 Hour comprehensive health history,
including health conditions,
allergies, medications.
3. Pt will disclose how last
appointment went including feelings
after appointment.
4. Pt will consent to having
blood pressure and pulse taken
before appointment.
5. Pt will report his chief
complaint
6. Pt will consent to CHX rinse
7. Pt will consent to wear the
patient napkin and eye protection
8. Pt will consent to EIE exam.
9. Pt will understand findings
of EIE exam.
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patient to remain still
21. Explain to pt that todays
cleaning is over. Explain to pt to
continue to breath full oxygen
through nose
22. Pt provides feelings of
todays cleaning. Observe and write
in pt chart
23. Give patient explanation of
possiable post op pain, explain of
possiable sensitivity. Explain to
patient to keep clean with improved
oral hygiene, Recommend anti-
inflammatory for pain along with a
CHX rinse to keep bacteria level
down. Educated Pt again about
treatment of dental decay and
refferal sent home with pt again.
24. Instruct pt to make next appt
with front desk
1. Obtain pt consent for Future goal not met at this time
treatment. Have Pt sign and date
consent to treat form and record on
chart.
2. Review patient’s health
history informing the patient why it
is important to have a current and
full completed health history
3. Pt discloses that past
treatment went well and healing
properly. Record in chart
4. Measure blood pressure and
pulse and record on pt chart. BP in
normal range
5. Ask the patient to explain if
they have a chief complaint and
record on patients chart.
6. Obtain patient consent for
CHX rinse. Record in patients chart
10. Pt will consent to disclosing 7. Pt places on safety glasses
test and allow to be dressed with pt
11. Pt will observe disclosed napkin
areas in hand mirror 8. Pt consents to preform EIE
12. Pt will understand PHP score exam
13. Pt will explain his current 9. Explain any EIE findings;
home care of previous quad of SRP Chart and findings
14. Pt will disclose current 10. Obtain consent and perform
feelings of smoking cessation PHP test
15. Pt will consent to wearing 11. Have patient observe
pulsometer during the appointment disclosed areas with hand mirror
16. Pt will consent to using the 12. Explain PHP score and
cavitron record in patients’ chart
17. Pt will consent to the 13. Educate the pt on brushing
administration of local anesthetic towards the gingiva along with using
18. Pt will consent to N2O2 a soft pick to use while commuting
19. Pt will follow directions to work
while admin N2O2 14. Positive reinforce smoke free
20. Pt will follow directions lifestyle
while admin Local Anesthetic 15. Obtain pt consent for him to
21. Pt will tolerate the switch to wear the pulsometer during the
full oxygen cleaning
22. Pt will tolerate SRP 16. Obtain pt consent to use
procedure well cavitron
23. Pt will understand post-op 17. Obtain pt consent to
directions, including pain administer local anesthetic
management and hygiene 18. Pt gives consent to
instructions. administer N2O2
24. Pt will schedule 6 week re- 19. Explain to pt deep breaths
eval. from nose only
20. Explain to pt of a little stick
while administering LA. Advised
patient to remain still
21. Explain to pt that todays
cleaning is over. Explain to pt to
continue to breath full oxygen
through nose
22. Pt provides feelings of
todays cleaning. Observe and write
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 in pt chart
23. Give patient explanation of
possiable post op pain, explain of
possiable sensitivity. Explain to
patient to keep clean with improved
oral hygiene
24. Instruct pt to make 6 week
re-eval appt with front desk
Apt #: 7- 6 week re-eval 1) Pt will consent to treatment. 1. Obtain pt consent for Future goal not met at this time
Date:       2) Pt will review and update treatment and record on pt's chart.
Time Req: 2 Hours health history. 2. Review pt's health history
3) Pt will update and review and note any changes since last appt.
dental history. 3. Review pt's dental history
4) Pt will show understanding and note any changes.
of importance of checking vital signs 4. Educate the pt the
before treatment. importance of checking vitals before
5) Pt will consent to having BP treatment.
measured along with pulse. 5. BP measured and pulse
6) Pt will report if he is having recorded on pt's chart.
a chief complaint. 6. Ask pt to state whether or not
7) Pt will consent to CHX rinse. they have a chief complaint.
8) Pt will understand purpose of 7. Obtain pt consent for CHX
eye protection and pt napkin and rinse.
wears them. 8. Explain the importance of
9) Pt will understand purpose of eye protection and pt napkin.
EIE exam to check for changes since 9. Explain purpose of EIE exam
last visit. and note any changes in pt's chart.
10) Pt will understand purpose of 10. Explain purpose of full
full mouth probing’s mouth probing
11) Pt will consent to full mouth 11. Obtain pt consent for full
probe. mouth probing and record in pt's
12) Pt will consent to PHP chart.
13) Pt will understand the use of 12. Obtain pt consent for CHX
xylitol gum rinse
14) Pt will understand dietary 13. Educate pt on chewing
items have on dental decay xylitol gum after meals
15) Pt will understand purpose of 14. Educate pt of fermentable
supragingival scaling and polishing carbs and their effect on the bacteria
16) Pt will understand purpose of that cause decay
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 intraoral photographs 15. Explain purpose of light
17) Pt will consent to intraoral supragingival scaling and polishing.
photographs 16. Explain to pt the before and
18) Pt will show understanding after pictures to show change after
and importance of scheduling a 3 SRP
month periodontal maintenance 17. Obtain pt consent to intra
appointment. oral photos
19) Pt will schedule 3 month 18. Explain again etiology of
SPM appointment       gingivitis and periodontal disease
and purpose of 3 month SPM appts.
19. Pt schedules next
appointment for 3 months.     
Apt #: 8- 3 Month SPM 1) Pt will consent to treatment. 1. Obtain pt consent for      
Date:       2) Pt will review and update treatment and record on pt's chart.
Time Req: 2 hours health history. 2. Review pt's health history
3) Pt will update and review and note any changes since last appt.
dental history. 3. Review pt's dental history
4) Pt will show understanding and note any changes.
of importance of checking vital signs 4. Educate the pt the
before treatment. importance of checking vitals before
5) Pt will consent to having BP treatment.
measured along with pulse. 5. BP measured and pulse
6) Pt will report if he is having recorded on pt's chart.
a chief complaint. 6. Ask pt to state whether or not
7) Pt will consent to CHX rinse. they have a chief complaint.
8) Pt will understand purpose of 7. Obtain pt consent for CHX
eye protection and pt napkin and rinse.
wears them. 8. Explain the importance of
9) Pt will understand purpose of eye protection and pt napkin.
EIE exam to check for changes since 9. Explain purpose of EIE exam
last visit. and note any changes in pt's chart.
10) Pt will understand purpose of 10. Explain purpose of full
full mouth probing’s mouth probing
11) Pt will consent to full mouth 11. Obtain pt consent for full
probe. mouth probing and record in pt's
12) Pt will consent to PHP chart.
13) Pt will understand the use of 12. Obtain pt consent for PHP
high fluoride toothpaste and benefits 13. Educate pt on benefits high
14) Pt will understand the need fluoride toothpaste; get rx for pt by
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 to have 3rd molars removed DDS. Record in chart
15) Pt will understand/consent to 14. Educate pt possiable abscess
the use of the cavitron that can form on molars and damage
16) Pt will consent to polishing on whole body
17) Pt will understand/consent to 15. Educate pt use of cavitron/
flossing obtain consent
18) Pt will understand/ consent 16. Obtain consent for polishing.
to fluoride varnish Record in chart
19) Pt will schedule 3 month 17. Educate pt on flossing
SPM appointment   technique. Obtain consent to clean
     interproximal with floss
18. Educate pt on fluoried
varnish. Obtain consent
19. Pt schedules next
appointment for 3 months.
Apt #:                        
Date:      
Time Req:      

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