Patient Specific Dental Hygiene Care Plan

Patient Name: removed for privacy Age: 29 Gender: M

Student Name: Scott Sonnier Date 3-6-17

Chief Complaint:
Need cleaning

Assessment Findings

Medical History At Risk For

Pt. is under the care of physician, last physical in last May----- --Almost a year, undiagnosed health problems
-meds taken by physician-------------------------------
Protonix------------------------------------------- ---burning mouth, candidiasis, dental erosion
Albuterol----------------------------------------- ---dry throat/mouth (increased caries)
Hospitalized for pericarditis -------------------------------------------- --- Recurrence may occur or become chronic
Has had surgery(oral)------------------------------------------------------ ---none
Has trouble breathing after walking a block------------------------ ----asthma attack, vasoconstriction
Has sinus problems-------------------------------------------------------- ----post nasal drip (bacteria build up in oral cavity) bad breath
Reflux-------------------------------------------------------------------------- ---tooth erosion, susceptible to caries, ulcers
Cold sores-------------------------------------------------------------------- ---- contagious, easily spread
Patient is not allergic to medications -------------------------------- --none

Social and Dental History At Risk For

Pt. smokes cigarettes (9yrs./ pack a day)---------------------------- ---Gums may not bleed, immune system suppressed, gum
disease, oral cancer, lung cancer, dry mouth, periodontal disease,
caries/ plaque increase, xerostomia, relapse
Has tried to quit times-------------------------------------------------- Increase risk of relapsing
Last Dental exam in June 2016 (cleaning)---------------------------- --caries, undiagnosed health problems ( updated xrays 2-2-17)

Last X-rays 2016(BWX)---------------------------------------------------- --- Caries, lesions, abscess, oral diseases (FMX needed)
Gums bleed floss------------------------------------------------------------ ---- Interproximal caries, gingivitis, periodontal disease
-- Sensitivity, attrition, damage to teeth, sore TMJ, tension,
Clenches jaws/Grinds teeth---------------------------------------------- headaches, malocclusion, pain, discomfort, tender
Drinks sweet tea 4 times a week--------------------------------------- --Increases risk of caries, demineralization, and plaque

Dental Examination At Risk For

Hypersthenic body type--------------------------------------------------- --diabetes, coronary heart disease, hypertension
Scattered Ephilids (sun exposure)-------------------------------------- ---Skin cancer
-scattered nevi on right and left hands --skin cancer
Dry-forehead -------------------------------------------------------------- --none
Hyperopia--------------------------------------------------------------------- --none
TMJ slightly deviates to the left(muscle tension/grinding)---- --TMJ problems/pain, poor oral care, biofilm, gingivitis,
periodontitis, headaches, pain, discomfort, soreness,
sialolithiasis
Mucosa(linea alba)--------------------------------------------------------- ---trauma

Dorsal surface of tongue plaque coated (not brushing)---------- -- Increased bacteria count, halitosis, transmission of bacteria
thru mouth easier, Caries, Periodontitis, Malodor, Gingivitis,
Grinding/Clenching at night---------------------------------------------- --TMJ problems, attrition, headaches
Occlusion/WNL (mesognathic)------------------------------------------ ---none
-cross bite #23----------------------------------------------------------- --can need to malocclusion, crowding
Mouth breathing------------------------------------------------------------ --Xerostomia; increased risk of caries
Slight Generalized biofilm------------------------------------------------ --Plaque, Calculus, bacteria load, infection, periodontal disease,
gingivitis
Calculus ----------------------------------------------------------------------- -- bacteria load, infection, periodontal disease, gingivitis
Caries-------------------------------------------------------------------------- --Demineralization,Tooth loss, infection, tooth pain, abscess
Medications----------------------------------------------------------------- -- Xerostomia; increased risk of caries
Mouth breaths ------------------------------------------------------------- -- Xerostomia; increased risk of caries
Tobacco use------------------------------------------------------------------ --Reduces bleeding, periodontal disease, gingivitis , oral cancer,
bad breath, suppress immune system, gum disease, slower
healing
Slight generalized biofilm ----------------------------------------------- --gingivitis, periodontitis and caries, calculus
Scalloped architecture----------------------------------------------------- --None
Slightly red generalized tissues----------------------------------------- --Gingivitis, periodontist
Slight generalized edematous/spongy-------------------------------- --Gingivitis, periodontitis
Generalized smooth surface texture/Localized smooth and
shiny surface texture------------------------------------------------------
-- --Gingivitis and Periodontitis
Slight generalized rolled margins---------------------------------------
--Gingivitis and Periodontitis, recession
Recession
(#23,22,20 -1mm )-------------------------------------------
(#11 -2mm)---------------------------------------------------- --Periodontitis increased risk of root caries
Generalized Caries mand And max ----------------------------------- --Periodontitis
-- Demineralization, pain from exposed dentin
Toothbrush abrasion, Caries increase, Gingivitis and
Periodontitis increase, Calculus buildup between teeth
Mild periodontitis

Generalized Attrition on Max. and Mand. teeth-------------------

Home Care: Soft toothbrush, scrub brushing technique,
brushes 2x day, flosses sometimes/never, rinses sometimes,
Crest whitening toothpaste, No fluoride-----------------------------
Calculus------------------------------------------------------------------------
Periodontal Case Type: 2 Plaque Score:1.33 good
--Demineralization, pain from exposed dentin, caries risk
increased
--Toothbrush abrasion, Caries increase, Gingivitis and
Periodontitis increase, Calculus buildup between teeth
--increase bacteria buildup, gingivitis, periodontist
Bleeding Score:8.33 %

Gingival Inflammation: Generalized marginal

Biofilm: Generalized slight
Biofilm Retentive Features/Predisposing Factors: Calculus, defective restorations, caries, , medication, tobacco use

Dental Hygiene Diagnosis

Problem Etiology

1. Plaque-------------------------------------------------------------- -- Plaque is due to bacteria and food debris accumulating on the

teeth. Calculus deposits are a biofilm retentive feature, as well as the
patients lingual retainer. Plaque accumulates due to inadequate
home care, in this case, infrequent flossing. Plaque can lead to
 2.Periodontal Disease--------------------------------------------
3.Caries----------------------------------------------------------------
4. Smoking/Cessation----------------------------------------------
5.Attrition (clenching and grinding)----------------------------
Planned Interventions
Clinical Education
1. Plaque
Scaling hard deposit Define plaque (the accumulation of bacteria and
removal food on the teeth. Plaque is a white, sticky
substance)
Polishing soft deposit -Discuss consequences of plaque not being
removal removed effectively, 2x daily (caries, stain,
calculus build up, gingivitis, periodontitis)
Fluoride application -Discuss and demonstrate proper brushing
techniques
-Reduce plaque score by .3 or more at each
appt.
demineralization, caries, calculus formation, and gingival
inflammation.
-- Periodontitis is an oral disease process that destroys bone and
gingival tissues. Patient does have mild bone loss around missing
teeth; and she stated that her mother also had periodontal disease.
--Oral home care, bacteria, not flossing properly , lack of
fluoride
-- Behavior change; social environment change
--- Attrition due to bruxism. Patient clenches due to habit and
stress. Patient also clenches and grinds at night. Can lead to
tooth sensitivity, attrition, tooth damage, sore TMJ, tension
headaches
Oral Hygiene Instruction
Due to improper brushing, flossing, and home
care. Plaque can lead to demineralization, caries,
calculus, gingival inflammation. Tooth brushing
technique; Reduce plaque scores at upcoming
appointments. Maintain brushing twice a day.
 2. Periodontal Disease
-Define periodontal disease (the inflammation
and apical movement of gum tissue due to
bacteria. Process is irreversible; however, it can
be halted.
-Discuss and demonstrate flossing (each night
before bed.. 40% of tooth surface is left dirty if
you do not floss...)
-Reduce bleeding score by 4% or more at each
appointment
Due to improper, flossing, home care, and
bacteria. Flossing. Teach the proper method on
flossing. Halt the progression of bone loss and
maintain pocket depths to 3mm or less. Take
bleeding score and give positive reinforcement
on and progress

3. Caries
-Define caries (demineralization of tooth
through a cariogenic process brought on my
bacteria adhering to tooth surface.)
Flossing; Get caries and appropriate restorations,
get plaque and biofilm out of interproximal
spaces; use fluoride supplements.

4. Smoking Cessation
-Define smoking cessation (process of
discontinuing tobacco smoking. Tobacco contains
Behavior change; Ask, Advise, Assess, Assist,
nicotine, which is addictive. Nicotine makes the
process of quitting often very prolonged and Arrange; Set quit date, encourage patient, offer
difficult. services

Expected Outcomes

Goals Evaluation Method Time Frame

 1 week
LTG 1: John will reduce bacteria levels and reduce plaque 1. Demonstrate proper brushing technique,
score by 1.00 to reach goal of .33 in 3 exams evaluate patients brushing method and take
plaque score at next appointment to see if
STG: Define plaque
patient applied their new knowledge
STG: Correctly demonstrate proper brushing technique
STG: Reduce plaque score by .25 at every appointment
LTG 2: Halt the progression of Periodontitis by stopping
2. Demonstrate proper flossing technique; 1 week after
bone loss and minimizing pocket depths from 4mm to 3mm
Evaluate patients flossing method; reduce first
or less and decrease bleeding score by 4% by the next
pocket depths and stop bone loss appointment
appointment
STG: Define Periodontitis
STG: Correctly demonstrate proper flossing technique
STG: Show an improvement in pocket depths and bleeding
score 3. Referral for dental restorations on lesions;
use of fluoride on demineralized surfaces
LTG 3: Caries restored and defective restorations fixed 1 week after
STG: Define caries/process second
appointment
STG: Use fluoride once a day at home
4. Set quit date and see if patient still follows
STG: Get carious lesions restored; save up money 1 week after
through; encourage patient at every
LTG 4: Tobacco Cessation; stop smoking within a 1 week third
appointment; decrease staining and odor
appointment
STG: Set quit date (week after last appointment)
STG: Encourage patient at every appointment
STG: Reduce stain and decrease risk of caries

Prognosis Explain your prognosis

Good Mr. Toney was unaware of his generalized caries problems that followed his daily poor oral
Fair hygiene care. He is concerned with his oral health and the appearance of his smile. Patient
Poor understands his oral effects from his addiction to tobacco and would like to correct the
Questionable problems. With continuing education and assistance, I think the patient and myself can work as
Hopeless
 a team to lower plaque score, bleeding score and the progression of periodontitis, and stop the
progression of any trauma or pain that could be associated with his bruxism.

Appointment Plan

Appt # Plan for Treatment Plan for Education, Counseling or Oral Hygiene Instruction
Update Medical/Dental History -Define plaque
1 Pre-Rinse -Discuss at risk issues associated with inadequate or
Take plaque score infrequent plaque removal (caries, stain, calculus, gingivitis,
Patient Education periodontitis)
Scale UR quad -Educate patient on correct brushing
-Evaluate patients brushing technique; correct if needed
- Repeat plaque score and see if there was improvement

Update Medical/Dental History -Define periodontal disease and potential for disease
2 Pre-Rinse progression if not halted
Take plaque score -Educate patient on flossing and give instructions for nightly
Check bleeding score flossing.
Patient Education -Demonstrate flossing; watch patient floss
Scale UL quad -Quick review of brushing from previous appointment, ask if
patient can comply thus far
-check bleeding score and look for improvement
Update Medical/Dental History -Define cavities and its process in tooth demineralization and
3 Pre-Rinse the health benefits if oral care is not changed.
Take plaque score -Encourage patient to make an appointment with his DDS for
Patient Education a prescribed fluoride treatments
Scale LR quad -Quick review of previous appointments and skills; evaluate
patients compliance.

Update Medical/Dental History Review previous appointment skills.

4 Pre-Rinse -Define smoke cessation and set quit date one week after this
Take plaque score appointment and see if patient still follows through;
 Scale LL quad encourage patient at every appointment; decrease staining
Plaque Free and odor.
Fluoride Treatment -Update status on DDS appointment for fluoride treatment
and new restorations to cavities that need care.
-Put patient on 4 month recall.
Referrals: DDS for caries treatment, mouth guard, restorations, attend behavioral change meetings (smoking)
Recall Interval: 4 month recall