Patient Specific Dental Hygiene Care Plan

Patient Name _________________________ Age _27________ Gender: M F

Student Name __Alissa Castellon__________________ Date _4/4/17___

Chief Complaint: Needs cleaning

Assessment Findings

Medical History At Risk For

Last physical 2007 ------------------------------------------------------- Unknown
Had a baby (2016)---------------------------------------------------------- None
Taking escitalopram oxalate (Lexapro)------------------------------- Xerostomia/drowsiness/dizziness/upset stomach
Taking ethinyl estradiol (birth control)------------------------------- Nausea/vomiting/headache/abdominal cramps
Treated for asthma as a child (controlled)--------------------------- None

Social and Dental History At Risk For

Last dental visit 2014 ----------------------------------------------------- Gingivitis/perio
Gums bleed when flossing----------------------------------------------- Gingivitis/perio
 Dental Examination At Risk For
Mesognathic----------------------------------------------------------------- None
Scattered ephilids---------------------------------------------------------- Cancer
Picked cuticles on hands-------------------------------------------------- None
Dry hands--------------------------------------------------------------------- None
Scratches on left hand----------------------------------------------------- None
Scar above right eyebrow------------------------------------------------ None
Scattered nevi--------------------------------------------------------------- Cancer
Myopia------------------------------------------------------------------------ None
Red/chapped lips----------------------------------------------------------- Infection
Dry/cracked vermillion---------------------------------------------------- Infection
Dry/chapped commissures----------------------------------------------- Infection
Purplish Pharyngeal pillars----------------------------------------------- Unknown
Linea alba (cheek sucking)----------------------------------------------- Cancer
Bilateral mandibular tori------------------------------------------------- Ulcers/overgrowth/interfere with speech or eating

Soft Tissue:
Moderate biofilm(gen)--------------------------------------------------- Caries/gingivitis
Color: Red (man)------------------------------------------------------------ Gingivitis/perio
Consistency: Slightly edematous/spongy (man)------------------- Gingivitis/perio
Surface texture: Smooth & shiny (man)----------------------------- Gingivitis/perio
Papillae shape: Normal--------------------------------------------------- None
Margin shape: Rolled (man)--------------------------------------------- Gingivitis/perio
Bleeding: None-------------------------------------------------------------- None
Position of margin: Recession (1mm #20-22, 27) Root exposure
Pocket Depth 4 (#19)------------------------------------------------------ Periodontitis
Open contact (8&9)-------------------------------------------------------- None
Periodontal Case Type: 2 Plaque Score: _1.6__ Bleeding Score: _0%____

Gingival Inflammation: Marginal, localized (man)

Biofilm: Moderate, Generalized
Biofilm Retentive Features/Predisposing Factors: None

Dental Hygiene Diagnosis

Problem Etiology

Plaque------------------------------------------------------------------------- Not brushing correctly

Gingivitis---------------------------------------------------------------------- Not flossing or rinsing enough
Tori----------------------------------------------------------------------------- Developmental
 Planned Interventions

Clinical Education Oral Hygiene Instruction

Plaque It is a white, sticky biolfilm substance Brushing/flossing/regular cleaning to reduce
Scaling hard deposit on the teeth. Remove by brushing and flossing. plaque score
removal It causes gingivitis, perio and caries.

Polishing soft deposit Gingivitis It is reversible inflammation of the Brushing/flossing/antiseptic rinse

removal gingiva that bleeds easily. It is halted by flossing
and brushing. It can lead to periodontitis and
Fluoride application bone loss.

Caries It is decay that eats away and Brushing/flossing/regular cleaning/fluoride

demineralizes the teeth. It can vary in size and Keep sugar in take with meals while drinking
color and can be caused from diet and oral water throughout the day
home care. It can lead to endodontic therapy if
 left untreated. Carious lesions are caused by
bacteria, plaque and a vulnerable tooth surface

Xerostomia- is a dryness in the mouth which Brush/floss/alter medication dosage/drink plenty

may be associated with a change in the of fluids/use mouthwash without alcohol/
composition of saliva, reduced salivary flow or
have no underlying cause such as not drinking
enough fluids, sleeping with mouth open or
medication side effects. Xerostomia can lead to
carious lesions because saliva helps prevent
tooth decay

Expected Outcomes

Goals Evaluation Method Time Frame

6 months
LTG 1: Reduce plaque score to from 1.6 to 0.5 1. Watch brushing
STG: Define plaque Evaluate plaque score
STG: Correctly demonstrate brushing
STG: Reduce plaque score by .2 each visit
LTG 2: Halt perio 2. Watch flossing 6 months
STG: Define perio Evaluate bleeding score/pocket depths
STG: Correctly demonstrate flossing
 STG: Keep recession at 1mm with no new spots
LTG 3: Treat xerostomia
STG: Define xerostomia
STG: educated on at home fluoride/oral care
STG: education on at home aids for xerostomia
3. Ask patient about xerostomia 4 months
Ask patient about home fluoride and oral care
Send patient home with samples of home aids

Prognosis Explain your prognosis

Good Patient has good home health care, but the patient needs to be shown better brushing
Fair techniques so that she doesnt scratch her teeth or gums by brushing too abrasively.
Poor
Questionable
Hopeless

Appointment Plan

Appt # Plan for Treatment Plan for Education, Counseling or Oral Hygiene Instruction
Periodebridement on UL quadrant Reduce plaque score to 0.5 by brushing in the morning and
1 Check plaque score (.2) at night, using the Bass method and flossing.
Probe for bleeding score (2%)

Periodebridement on UR quadrant Halt perio by proper oral care, using floss and water pick to
2 Check plaque score (.2) clean interproximately.
Probe for bleeding score (2%)
 Halt anymore recession from appearing correct brushing
3 Periodebridement on LR quadrant method.
Check plaque score (.2)
Probe for bleeding score (2%)

Halt anymore recession from appearing correct brushing

4 Periodebridement on LL quadrant method.
Check plaque score (.2)
Probe for bleeding score (2%)

Referrals: None
Recall Interval: 6 months