Patient Specific Dental Hygiene Care Plan

Patient Name: Age: 27 Gender: M

Student Name: Brenda Garcia Date: 3-21-18

Chief Complaint: Cleaning

Medical History At Risk For

Surgeries include:
1. Index finger surgery December 2015 1. None
2. No physical listed 2. Undiagnosed health conditions

Social and Dental History At Risk For

1. Had 4-6 cavities on the last dental visit on March 2015 1. Caries, infection

Dental Examination At Risk For

1. Pyknic body type 1. None
2. Right index finger missing etiology: trauma 2. None
3. Right fingernail broken etiology: trauma 3. None
4. Left hand 3mm scar by ring finger etiology: trauma 4. None
5. Mesognatic 5. None
6. Scattered ephelides etiology: developmental 6. Skin cancer
7. Red acne on lower right chin ad on right side of nose and 7. None
on left check under eye etiology: bacteria
8. Sclera- redness etiology: astrain 8. None

9. Left side 2 mm macule on chin under lip etiology: 9. Skin cancer

developmental

10. Left nodule 2mm, 1 inch from acoustic meatus etiology: 10. Skin cancer
developmental

11. Submandibular unilateral on the right lymphadenopathy 11. Infection

its mobile etiology: bacteria

12. Cheek bite marks on posterior right and left etiology: 12. Infection
trauma

13. Right molar occlusion unclassifiable 13. Plaque retention, malocclusion, interference with eating

14. Right canine, left canine, and left molar are class III on 14. Malocclusion
occlusion

15. Architecture: scalloped 15. None

16. Color: Red on #14 and #15 papilla in margin on facial and 16. Periodontitis
lingual. Whitened and red on upper posterior on left
(tissue sloughing)

17. Consistency: edematous/spongy localized upper left on 17. Periodontitis

#14 and #15

18. Surface texture (papillary & maxillary): Stripped 18. Periodontitis

19. Shape, papillae: Bolbous #14 & #15 darker red lingual 19. Periodontitis
papillae is swollen
 20. Shape, margins: Rolled on #14 & #15 on lingual 20. Periodontitis

21. Position of margin (recession): #28 (2mm) #29 (1mm), 21. Periodontitis
localized 1-2 mm on posteriors

22. Pocket depths are 4’s and 5’s on posterior teeth 22. Periodontitis

23. Bleeding is generalized on posterior teeth 23. Periodontitis

24. Mild horizontal bone loss on UR and LL #2, #3,#28, #29 24. Periodontitis, bone loss, increased periodontitis if not
stopped
25. Vertical horizontal bone loss on UL and LL #12, #13, #20, 25. Periodontitis, bone loss, increased periodontitis if not
#21 stopped

26. Widened PDL, LR #18, #27, #31 26. Periodontitis

27. Calculus UR, UL, LL, LA, LR generalized 27. Periodontitis, decay

28. Caries LL #18 28. Microbial bacteria

Periodontal Case Type: 2 Plaque Score: 3.16 Fair Bleeding Score: 12.5 %

Gingival Inflammation: Localized #14 and #15 on papillary and marginal

Biofilm: Slight and generalized on maxillary and mandibular posterior molars
Biofilm Retentive Features/Predisposing Factors: Calculus, malposition teeth, caries, nutrition

Dental Hygiene Diagnosis

Problem Etiology
1. Plaque ------------------------------------------------------------------- 1. Environmental factors
2. Periodontitis ----------------------------------------------------------- 2. Plaque accumulation
3. Caries -------------------------------------------------------------------- 3. Microbial bacteria

Planned Interventions

Clinical Education Oral Hygiene Instruction

Teach patient about plaque
Scaling – hard deposit 1.Plaque--------------------------------------------------- Teach brushing methods
removal
Review brushing/flossing
Polishing – soft deposit 2.Periodontitis------------------------------------------ How to brush in the posterior
removal Halt progression

Fluoride application Behavior change (diet/nutrition)

3.Caries--------------------------------------------------- Review methods of brushing, rinsing, and flossing
Use of fluoride

Expected Outcomes

Goals Evaluation Method Time Frame

LTG 1: Patient will reduce her plaque score to 2.0. 1. Plaque/ brushing
STG: Patient will define plaque by 2nd appointment. Demonstrate proper brushing
technique, evaluate patients End of treatment
STG: Patient will demonstrate bass brushing method.
brushing method and take
STG: Patient will reduce plaque score by next appointment. plaque score at next
appointment to see if patient
applied their new knowledge
LTG 2: Patient will halt the aggression of periodontitis by decreasing his
bleeding score by 11% until it becomes 1 % or lower.
STG: Patient will define periodontitis. 2. Periodontitis/ flossing

STG: Patient will correctly demonstrate proper flossing. Demonstrate proper flossing
technique; Evaluate patients End of treatment
STG: Patient will show improvement in bleeding scores. flossing method; reduce pocket
depths, stop bone loss, bleeding
score
LTG 3: Patient will have her carious lesion restored.
STG: Patient will define caries by end of treatment.
3. Caries/ fluoride
STG: Patient will schedule an appointment with the dentist for 3-4 months by
end of treatment for a cleaning and as soon as possible to treat for caries.
Behavior change (diet/nutrition)
STG: Patient will choose to use home fluoride by the end of treatment. Review methods of brushing, 3 months
rinsing, and flossing
Usage of Fluoride

Prognosis Explain your prognosis

Good Patient has shown interest in seeking dental care and is willing to utilize the methods of
Fair preventive care in daily oral hygiene routine and is classes as a fair prognosis because he
Poor is a periodontal class 2 and has extensive decay. He it at high risk for continuous disease
Questionable and tooth loss because of current oral conditions.
Hopeless
 Appointment Plan

Appt # Plan for Treatment Plan for Education, Counseling or Oral Hygiene Instruction
Medical/ dental HS 1. Plaque
1 Pre-rinse 2. Brushing
Plaque/bleeding score 3. Flossing
Patient Ed
Scale UL Define Plaque
X Teach proper techniques of brushing
Watch patient brush
Adjust/reeducate brushing if needed

Medical/ dental HS 1. Periodontitis

2 Pre-rinse 2. Flossing
Plaque/bleeding score
Patient Ed Define Periodontitis, state how to halt progression
Scale LR Teach patient how to floss
Adjust/reeducate flossing

Medical/ dental HS 1. Caries

3 Pre-rinse 2. Fluoride
Plaque/bleeding score Behavior change (diet/nutrition)
Patient Ed Review methods of brushing, rinsing, and flossing
Scale UR Usage of Fluoride

Competency quadrant
X
 Medical/ dental HS Evaluate progress, make suggestions. re-educate
Pre-rinse
4 Plaque/bleeding score
Patient Ed X X
Apply Fluoride
Polish all quadrants X X
Scale LL

Referrals: Current carries

Recall Interval: 3-4 months