Patient Specific Dental Hygiene Care Plan

Patient Name Removed for privacy

Student Name Victoria Sisco

Age 22

Gender:

Date 2-19-16

Chief Complaint: To have teeth cleaned and x-ray

Medical History
#21 Birth of a child
#93 sensitive front teeth
#95 grinding of teeth at night

Social and Dental History

3 years since last dental visit
Soft toothbrush
Brushes 2 times a day
Only flosses about 5 times a week
Only rinses about 5 times a week
No Flouride

At Risk For
#21 none
#93 Recession, root exposer
#95 sore jaw, TMJ issues, abfraction, sensitivity

At Risk For
Plaque
Calculus
Caries
Gingivitis
Periodontitis
Recession
Sensitivity
Brown Stain

Dental Examination
1. Aesthetic body type
2. Scattered Calcium deposits in finger nails
3. Mesoganathic profile
4. Scattered Ephilides
5. Wears Glasses; Myopia
6. 2 Fever Blisters on the left side above the
commissure
7. TMJ deviates to the left
8. Slightly red incisive papilla
9. Partially erupted maxillary third molars
10. Bilateral tori more prominent on right
11. Grinds teeth at night
12. Clenches at night
13. Tissues Scalloped
14. Tissues red especially mandibular anterior
facial and lingual
and mandibular posterior
lingual
15. Tissues edematous/spongy
16. Surface texture smooth and shiny (papillary,
marginal, & attached)
17. Shape of papillae bulbous (mand. Ant. facial
and lingual)
18. Shape of Margins rolled (mand. Ant. Facial and
lingual)
19. Localized recession #5, #12, #24, #25
20. Localized 4mm Pockets on #30, #18, #2
21. Generalized Bleeding

Periodontal Case Type: 2

At Risk For
none
none
None
Skin cancer
None
Viral infection
TMJ Problems, Soreness, Tenderness, Lock Jaw,
Muscle Tension, Limited opening, Abfraction,
Attrition
8. Soreness, tenderness
9. Risk of not fully erupting and moving teeth
10.
None
11.
TMJ Problems, Soreness, Tenderness,
Lock Jaw, Muscle Tension, Limited opening,
Abfraction, Attrition
12.
TMJ Problems, Soreness, Tenderness,
Lock Jaw, Muscle Tension, Limited opening,
Abfraction, Attrition
13.
-21 Gingivitis, periodontitis, tooth loss
1.
2.
3.
4.
5.
6.
7.

Plaque Score: 3.6

Bleeding Score: 4.6%

Gingival Inflammation:
Biofilm: slight, Generalized
Biofilm Retentive Features/Predisposing Factors: Calculus and Malposistioned teeth
Dental Hygiene Diagnosis
Problem

Related to Risk Factors or Etiology

1. Plaque

1. Results to calculus demineralization caries

2. Periodontitis

Due to infrequent dental visits, poor hygiene,

bacteria

3. TMJ

2. Bleeding gums, loss of attachment, Halitosis,

periodontal pockets, gingivitis periodontitis.
Periodontitis is irreversible, but can be halted.
Gingivitis is reversible, if caught soon enough
Due to infrequent dental visits, poor hygiene,
bacteria
4. Sore jaw, tired and over worked muscles
due to clenching and grinding
wear facets and risk of caries

Planned Interventions
Clinical
Scaling hard
deposit
removal
Polishing soft
deposit removal
Fluoride application

Education
1. Plaque
- Describe what it is (sticky
deposits of bacteria)
- What it looks like (sticky, clear
film, food debris)
- How to remove it
(brushing/flossing)
- What it causes (if left to harden it
becomes calculus. If not cleaned
then the gums will get irritated
which leads to gingivitis)
2. Periodontitis
- Describe what it is (bacterial
infection caused by plaque, loss
of attachment of tooth from
socket)
- What it looks like (puffy, red
gums that easily bleed)
- What it causes (if not halted, it
can lead to loss of overall tooth)
3. TMJ
- Define TMJ

Oral Hygiene Instruction

1.
-

Brushing mechanically 2x a day

Flossing

Brushing 2x a day
Flossing
Professional cleaning every 3
months

2.

3.
- Find a dentist a.s.a.p.
- Look into getting a night guard

- What causes TMJ

- How to prevent further pain from
TMJ

Expected Outcomes
Goals
LTG 1: To reduce plaque score to .1 or less

Evaluation Method
1. Take plaque score at every visit

STG: Define plaque

STG: Define brushing (2x a day)

Time Frame
@ 3rd
appointment/
end of
treatment

STG: Help brush with correct brushing style

LTG 2: Halt progression of periodontitis
STG: Define periodontitis and (gingivitis)

2. Take new bleeding score/visual

inspection of gums

STG: Demonstrate flossing (2x a day)

@ 3rd
appointment/
end of
treatment

STG: Reduce bleeding score by 1.0 each

appointment
LTG 3: Explain TMJ and causes
STG: Define TMJ
STG: explain wear facets and increased risk of
caries due to dentin exposer

3. Find a dentist a.s.a.p. and get a

night guard, get fluoride treatments to
help with abfraction thats occurred
9-12 mos
due to grinding

STG: Talk about finding a dentist and getting a

night guard (cost roughly around 400-700 for a
night guard)

Prognosis

Explain your prognosis

Good
Fair
Poor
Questionable
Hopeless

Patient has awareness of treatment plan and with more education I feel that
they will take action

Appointment Plan
Appt
#
1

Plan for Treatment

Dental/Med History
Take Plaque/bleeding score
Patient Education
Pre Rinse
Scale UR

Dental/Med History
Take Plaque/bleeding score
Patient Education
Pre Rinse
Scale UL

Plan for Education, Counseling or Oral

Hygiene Instruction
Define plaque
Teach patient how to properly brush
Watch patient brush
Adjust/reeducate brushing if needed

Define gingivitis and periodontitis

Teach patient how to floss
Watch patient floss
Adjust/reeducate flossing and/or anything from
previous session.

Dental/Med History
Take Plaque/bleeding score
Patient Education
Pre Rinse
Scale LL

Define TMJ
Teach patient about the importance of not grinding
or clenching their teeth
Talk to patient about maybe getting a night guard
Find DDS, discuss payments, scheduling
appointment
Adjust/reeducation anything from previous session

Dental/ Med History

Take Plaque/ Bleeding score
Patient education
Pre Rinse
Plaque Free
Flouride

Plaque Free
Fluoride
Adjust/reeducation anything from previous session

Referrals:
Recall Interval: 3 months