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Assessment Findings
Medical History At Risk For
Under care of physician Unknown
Prescription meds- TriNessa Frequent recall to evaluate gingival condition, xerostomia
Surgery- tubes in ears when child None
Seasonal allergy-sinus problems (no meds) Infection
Vitals: (1-25-17) BP 118/70, P 69 +2 reg, R 16 reg,easy,norm, T None
97.3, all WNL
Vitals: (1-30-17) BP 120/70 prehype, P 70 +2 reg, R 16 reg, None
easy, norm, T 98, WNL
4. Lingual retainer
Planned Interventions
Clinical Education Oral Hygiene Instruction
1. Caries Have restorative care on carious lesion in next 6
Scaling hard deposit months, use fluoride once a day, decrease sugar
removal intake
2. Plaque/ calculus
Polishing soft deposit Reduce plaque score to at least a 1.5 by final
removal appointment, correctly demonstrate brushing
3. Gingivitis
Fluoride application Lower bleeding score/maintain, correctly
demonstrate flossing, develop habit of flossing, 6
month recall to remove calculus
Expected Outcomes
Goals Evaluation Method Time Frame
6 months
LTG 1: have carious lesion restored 1.find DDS and make appointment in the next 6
(august 2017)
months
STG: define caries by next appointment treatment
should be
STG: use fluoride once a day complete
STG: save money for restorative care by 6 month recall
date (august 2017)
2.watch brushing technique and evaluate plaque Until plaque
LTG 2: reduce bacteria in mouth and maintain a low plaque score score is 1.5 or
score lower by last
appointment
STG: define plaque by next appointment
STG: reduce plaque score by .5 at each visit 3. watch flossing technique and evaluate
bleeding score Until bleeding
LTG 3: maintain a low bleeding score and develop flossing score is
habit lowered and
habit is
STG: define gingivitis by the end of todays appointment
developed by
STG: demonstrate proper flossing technique by the end of next recall
todays appointment date in 6
months
STG: lower and maintain bleeding score to 1.5 or lower by (august 2017)
6 month recall date (august 2017)
Prognosis Explain your prognosis
Good Patient is willing and ready to work on bettering her oral habits. She is interested in learning how
Fair to keep her retainer clean and she is willing to take care of her carious lesion.
Poor
Questionable
Hopeless
Appointment Plan
Appt # Plan for Treatment Plan for Education, Counseling or Oral Hygiene Instruction
Check plaque score and bleeding score, calculus Address beginning plaque score and bleeding score, define
1 detection,retakes on radiographs- 2 hr. caries, make an appointment to have restoration work on
active caries and complete treatment by 6 month recall,
begin fluoride use once a day
Perio debridement on maxillary right and left, Define plaque, correctly demonstrate brushing, review
2 Check plaque and bleeding score, plaque and bleeding score, review caries definition
2 hr.
Polish all 4 quadrants, check final plaque score and Review plaque and bleeding score from initial
bleeding score- 2 hr appointment to final appointment, review brushing and
flossing techniques, review definitions for caries, plaque,
4 and gingivitis, review appointment with DDS for caries
treatment