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 3. Ask patient about xerostomia 4 months
STG: Define xerostomia Ask patient about home fluoride and oral care
STG: educated on at home fluoride/oral care Send patient home with samples of home aids
STG: education on at home aids for xerostomia
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
