Care Plan Student Name: ___Shelby Holle_____

Patient: ____ ____ Date of data completion: ___4/01/14_____

Date submitting plan: _____4/01/14________
Synopsis of Patient History
Age: 4
Se!: "
#ace: $aucasian
%eight: &
P'ophy $lass: (
Pe'iodontal )ype: &
1
st
Appointment 2
nd
Appointment 3
rd
Appointment
*lood P'essu'e: 1&+/,& p'e-hype. 't/
a'm. not %N0
1&4/,&/ p'e-hype. 't/
a'm. not %N0
1&&/1,. p'e-hype. 't/ a'm.
not %N0
Pulse #ate: 1&/ 2&. no'mal. %N0 11. 2&. no'mal. %N0 14. 2&. no'mal. %N0
#espi'ation #ate: 1+. 'egula'. easy.
no'mal. %N0
1. 'egula'. easy.
no'mal. %N0
1+. 'egula'. easy. no'mal.
%N0
Pla3ue Sco'e: N/A N/A 1/1 - good
*leeding Sco'e: N/A N/A 1/1&4
Amount and gene'al location of pla3ue: Slight. gene'ali5ed
$ont'ibuting facto's fo' pla3ue 'etention: $alculus
Current Oral Self Care Methods
Type Frequency
)oothb'ush/b'ushing
method
Soft *'istle A"/P"
)oothpaste $'est (-D %hitening A"/P"
6loss 7es &! pe' 8ee9
Po8e' Assisted Appliances N/A
#inses 7es Daily
6luo'ide :n toothpaste -
;the' N/A N/A
Medical!ental History Summary"
1/ :dentify any medical p'oblems that the patient might ha<e/
None/
&/ :dentify any medical p'oblems that might complicate dental t'eatment. and 8hat steps should be ta9en to
minimi5e o' a<oid thei' occu''ence/
None/
(/ 0ist any alle'gies that the patient has 'epo'ted/
None/
4/ 0ist medications cu''ently ta9en by the patient and the dental implications of each/
1/ $lona5epam: dental implications = poo' 8ound healing. !e'ostomia. sei5u'es. assess sali<a'y flo8/
&/ >scitalop'amdent: dental implications = !e'ostomia. ?: side effects. semi supine chai' position fo'
patient comfo't. assess sali<a'y flo8/
/ Does the patient smo9e o' use tobacco p'oducts@
Document f'e3uency and type of tobacco p'oducts used/
7es uses tobacco = dip 1! pe' 8ee9/
+/ %hen 8as the patientAs last dental <isit@
%hat t'eatment 8as 'ende'ed at this appointment@
10 months ago = Bune &01(/ Dental cleaning 'ecei<ed/
1/ %hat is the chief complaint of the patient@
(Listed on M/D History)
)he patient states he needs a dental e!am/ CcleaningD
,/ 0ist any othe' medical info'mation that you feel is pe'tinent to the t'eatment of this patient/
None/
E/ 0ist any othe' dental info'mation that you feel is pe'tinent to the t'eatment of this patient/
)he patient bleeds 8hile flossing his teeth the'efo'e bleeding may occu' du'ing t'eatment/
10/ Assess the patientAs cu''ent le<el of lea'ning and state 'ationale/
Must be record in progress notes at every appointment.
At p'esent. the patientAs cu''ent le<el of lea'ning is self-inte'est/ Although the patient is not inte'ested in
3uitting the use of tobacco p'oducts at this time. he is ho8e<e' inte'ested in lea'ning the effects that using
tobacco has on the o'al ca<ity/ He is also <e'y attenti<e th'oughout the pape'8o'9 and p'ocedu'es as9ing
3uestions and 8anting to 9no8 ho8 it 'elates to his o<e'all o'al health/
11/ 0ist all positi<e findings f'om you' data collection on the Chart of Positi#e Findin$s%
See attached/
1&/ Fse the positi<e findings to fill out the Chart of Patient &eeds/
See attached/
1(/ 6o' e<e'y p'oblem listed on the $ha't of Patient Needs. state the lon$ term $oals fo' dental hygiene
t'eatment that ha<e been established by the clinician and the patient/ Fnde' each long te'm goal. state at
least & short term $oals that 8ill help the patient attain the long te'm goals/
Plaque/Brushing
LTG - 1.) The patients plaque score is at the minimal good level of a 1.7 his
goal !ill "e to lo!er the plaque score "# $.% at ever# appointment until he reaches
e&cellent .$.
'TG - 1.) The patient !ill descri"e plaque and ho! it forms "# the second
appointment.
(.) The patient !ill correctl# use the )ass Technique "# the third appointment.
*.) The patient !ill choose to +oss four times per !ee, "# the fourth
appointment.
Periodontitis/Flossing
LTG - 1.) The patient !ill halt the progression of the disease "# improving dail#
oral h#giene regimens and !ill also reduce his "leeding score 1.1(- to $- "# the
end of treatment.
'TG - 1.) The patient !ill descri"e periodontitis "# the second appointment.
(.) The patient !ill correctl# use the 'pool .ethod "# the third appointment.
*.) The patient !ill choose to +oss four times per !ee, "# the fourth
appointment.
Self-exam Techniques for Changes in the Oral Cavity
LTG-1.) /lthough the patient is not interested in quitting the use of to"acco0 he
!ill tr# to improve his overall gingival health and !ill learn self-e&am techniques to
notice an# changes in his oral cavit#.
'TG- 1.) The patient !ill descri"e the e1ects of spit to"acco on the oral cavit# "#
the second appointment.
(.) The patient !ill s!itch the side he uses dip on so that the tissues
currentl# damaged can heal "# the third appointment.
*.) The patient !ill learn to do self-e&am techniques to notice an# changes in
the oral cavit# "# the fourth appointment.
14/ State the clinicianAs assessment of the possibility of the patientAs goal attainment/
(Ex. excellent, good, fair, guarded, poor).
Explain your answer.
(Consider life-styles, financial ability, social/cultural bacground, etc.)
)he possibility of the patientGs goal attainment is good/ He is inte'ested in the effects tobacco can ha<e
on his o'al ca<ity as 8ell as ma9ing changes in his daily o'al ca'e/ : ha<e made his goals attainable to 'each
a'ound his lifestyle and capability/
1/ Outline the info'mation to be p'esented in the th'ee Patient 'ducation Sessions%
:nclude the specific info'mation that 8ill be taught. the methods of p'esentation. and 8hat <isual aids
8ill be used/ Submit on a sepa'ate page/
Patient >d/ Session 1- Plaque(rushin$
Define pla3ue- Pla3ue is a stic9y. colo'less deposit of bacte'ia that is constantly fo'ming on the
tooth su'face/
Pla3ue has a Hslimy feelI 8hen you touch you' teeth 8ith you' tongue/ At fi'st. this slimy laye' is
f'agile and easily 'emo<ed by tooth b'ushing but if left alone pla3ue builds up and ha'dens
c'eating calculus on you' teeth 8hich has to be 'emo<ed by a dental p'ofessional/
Dental Pla3ue is the main cause of ca<ities and gum disease/
Pla3ue must be b'ushed off because it contains bacte'ia that 8ea9ens you' tooth enamel and
causes tooth decay and diseases such as ca'ies. gingi<itis. and pe'iodontitis/ )he bacte'ium
p'oduces acid that 'emo<es the mine'als f'om the enamel 8hich leads to ca'ies decay/ )he pla3ue
that is not 'emo<ed can cause i''itation to the fumes a'ound you' teeth 8hich leads to gingi<itis
C'ed. bleeding gums. s8ollenD pe'iodontal disease and tooth loss/
:n Just 4, hou's pla3ue 8ill double in its mass and also sta't to 'efo'm as soon as you stop
b'ushing/
:t is simple to p'e<ent pla3ue f'om building up if you a'e = (rushin$
) #eplace you' toothb'ush 8hen it begins sho8ing 8ea'. o' e<e'y th'ee months/
K 7ou should b'ush t8ice a day because pla3ue is constantly fo'ming on you' teeth/
K *'ushing at night is especially impo'tant because the pla3ue is sitting in the mouth since
you a'e not tal9ing. eating. o' d'in9ing/
K : 8ill inst'uct the *ass techni3ue because that is the best one : thin9 is fo' my patient/
Lisual aids : 8ill use: )ypodont. flip cha't. my patientGs pape'8o'9. toothb'ush. toothpaste.
demonst'ation toothb'ush. disclosing solution. cup. and cotton tip applicato'/
Patient >d/ Session &- PeriodontitisFlossin$
M Define Pe'iodontitis- A bacte'ial infection of all pa'ts of the pe'iodontium/ )his includes the gingi<a.
pe'iodontal ligament. bone. and cementum 8hich 'esults in irre#ersi*le tissue damage/
M #ega'ding Pe'iodontitis. you' gums pull a8ay f'om the teeth and fo'm a space. called a poc9et/ )hese poc9ets
get infected and sta't to b'ea9 do8n the bone and connecti<e tissue that hold you' teeth in place/
M :f pe'iodontitis is not t'eated the bones. gums. and tissue that suppo't the teeth a'e dest'oyed/
M Also. the teeth may e<entually become loose and ha<e to be 'emo<ed if the disease is not t'eated/
M )o help 8ith halting the p'og'ession of the disease you should: floss and b'ush t8ice daily and constantly
'etu'n fo' you' t8ice yea'ly dental <isits to get a cleaning/
M ;ne 8ay to p'e<ent pe'iodontitis is - Flossin$/
K 6lossing helps to imp'o<e you' o'al health by 'eaching bet8een places that you' toothb'ush cannot
get to/ :t 8ill also ma9e you' gingi<a healthie' and st'onge'/
K Do not use hea<y p'essu'e 8hile flossing you' teeth to p'e<ent cutting the gum tissue/
K :t is impo'tant to 'emembe' to slide the floss unde' the gum line gently and to floss each tooth
tho'oughly 8ith a clean section of floss/
K : 8ill inst'uct the Spool "ethod of flossing and the patient can sho8 me if it co''ectly 8o'9s fo'
him so he can ma9e flossing apa't of his o'al home ca'e/
M Lisual aids : 8ill use: typodont. flip cha't. floss. my patientGs pape'8o'9. 'adiog'aphs. disclosing
solution. cup. and cotton tip applicato'/
Patient >d/ Session (- Self+e,am Techniques for Chan$es in the Oral Ca#ity
M All fo'ms of tobacco a'e ha'mful. but the tobacco type. amount used. and du'ation of use can ha<e a
g'eat impact on the 'is9 fo' disease/
M Fsing tobacco causes tooth stains o' o<e'all tooth discolo'ation. bad b'eath. and an inc'ease in the
amount of dental pla3ue in you' mouth/ )he mo'e dental pla3ue. the ha'de' it is to 'emo<e 8hich e<entually
leads to calculus and tooth decay/
M )obacco inte'fe'es 8ith the function of gum tissue cells/ ?ums become damaged by sepa'ating f'om the
bone. lea<ing them open to infection/
M Ad<anced pe'iodontitis e<entually leads to bone dete'io'ation and tooth loss/
M S8itching the side of you' mouth that you dip on 8ill gi<e you' damaged tissues time to heal/
M Smo9eless )obacco is less 'is9y than smo9ing. though still dange'ous/ Some othe' effects a'e:
o Tooth A*rasion - ?'it and sand in smo9eless tobacco p'oducts sc'atches teeth and 8ea's a8ay
the ha'd su'face o' enamel/ P'ematu'e loss of tooth enamel can cause added sensiti<ity and may
'e3ui'e co''ecti<e t'eatment/
o -um .ecession - $onstant i''itation to the spot in the mouth 8he'e a small 8ad of che8ing
tobacco is placed can 'esult in pe'manent damage to pe'iodontal tissue/ :t also can damage the
suppo'ting bone st'uctu'e/ )he inJu'ed gums pull a8ay f'om the teeth. e!posing 'oot su'faces and
lea<ing teeth sensiti<e to heat and cold/ >'osion of c'itical bone suppo't leads to loosened teeth
that can be pe'manently lost/
o /ncreased Tooth !ecay - Suga' is added to smo9eless tobacco du'ing the cu'ing and p'ocessing
to imp'o<e its taste/ )he suga' 'eacts 8ith bacte'ia found natu'ally in the mouth. causing an acid
'eaction. 8hich leads to decay/
o Tooth !iscoloration and (ad *'eath - $ommon t'aits of long-te'm smo9eless tobacco use's a'e
stained teeth and bad b'eath/ "o'eo<e'. the habit of continually spitting can be both unsightly
and offensi<e/
o &icotine !ependence - Nicotine blood le<els achie<ed by smo9eless tobacco use a'e simila' to
those f'om ciga'ette smo9ing/ Nicotine addiction can lead to an a'tificially inc'eased hea't 'ate
and blood p'essu'e/ :n addition. it can const'ict the blood <essels that a'e necessa'y to ca''y
o!ygen-'ich blood th'oughout the body/ Athletic pe'fo'mance and endu'ance le<els a'e dec'eased
by this 'eaction/
o 0nhealthy 'atin$ Ha*its - $he8ing tobacco lessens a pe'sonGs sense of taste and ability to
smell/ As a 'esult. use's tend to eat mo'e salty and s8eet foods. both of 8hich a'e ha'mful if
consumed in e!cess/
o Oral Cancer - %ith the p'actice of Nche8ingN and Ndipping.N tobacco and its i''itating Juices a'e
left in contact 8ith gums. chee9s and/o' lips fo' p'olonged pe'iods of time/ )his can 'esult in a
condition called leu9opla9ia/ 0eu9opla9ia appea's eithe' as a smooth. 8hite patch o' as leathe'y-
loo9ing 8'in9led s9in/ :t 'esults in cance' in ( pe'cent to pe'cent of all cases/
o Other Cancers - All fo'ms of smo9eless tobacco contain high concent'ations of cance'-causing
agents/ )hese substances subJect use's to inc'eased cance' 'is9 not only of the o'al ca<ity. but
also the pha'yn!. la'yn! and esophagus/
o !A&-'. S/-&S - :f you use smo9eless tobacco you should be on the loo9out fo' some of
these ea'ly signs of o'al cance':
O A so'e that does not heal
O A lump o' 8hite patch
O A p'olonged so'e th'oat
O Difficulty in che8ing
O #est'icted mo<ement of the tongue o' Ja8s
O A feeling of something in the th'oat
Pain is 'a'ely an ea'ly symptom/ 6o' this 'eason. all tobacco use's need 'egula' dental chec9-
ups/
)he follo8ing a'e <ideos : ha<e found f'om 7ou )ube. these <ideos 8ill help you lea'n ho8
to do int'a-o'al e!ams and 8ill help in the p'e<ention of o'al cance':
http://youtu/be/+hP_0#A:u#4 - ;'al $ance' P'e<ention = :nt'a-o'al Self-e!am
http://youtu/be/()F+oS&,o'7 - :nt'a-o'al e!am
P'acticing these self-e!am techni3ues 8ill teach you ho8 to notice any changes in you' mouth. gums. tongue.
etc/
M )hese a'e handouts that e!plain 8hat to loo9 fo' 8hile doing self-e!amination. : 8ill ha<e these to gi<e to my
patient at the end of ou' session/
http://888/3uittobacco/com/facts/effects/htm
http://888/mhhe/com/socscience/hhp/fahey1e/8ellness_8o'9sheets/8ellness_8o'9sheet_0E/pdf
M Lisual aids : 8ill use: typodont. flip cha't. statistics. <ideos. handouts. and patientAs pape'8o'9/
1+/ #efe''als:
None/
11/ #ecall Schedule:
+ months/
11% Chart of Positi#e Findin$s
Med!ent History
Fses tobacco = dip 1! pe' 8ee9
?ums bleed 8hen flossing
:s on medication
Has had su'ge'y
/ntra',tra Oral ',am
Hype'sthenic = big boned. mesognathic p'ofile. scatte'ed ephelids on chee9s fo'ehead and a'ms
eti: sun e!posu'e.
'ed pustule less than 1 mm 'ound on chin & inches belo8 lo8e' lip eti: sha<ing
0ifted ne<i left eyelid eti: de<elopmental. s9in tags on both lids eti: de<elopmental.
myopia eti: de<elopmental
)onsils 'emo<ed eti: su'ge'y. bilate'al linea alba on buccal mucosa Q late'al tongue su'faces eti:
chee9 and tongue biting. 1 mm 8hite 'ounded ulce' on left buccal mucosa eti: bacte'ia/t'auma
>!otosis on mandibula' Q ma!illa'y attached gingi<a. mandibula' lingual to'i &mm bilate'al =
both eti: de<elopmental
( mm 'ed/8hite pustule on ha'd palate unde' incisi<e papillae et: t'auma
"id-line shift &mm to the left
-in$i#alPeriodontal Assessment
Slight gene'ali5ed biofilm. biofilm 'etenti<e featu'es = calculus. p'edisposing facto's =
medication. tobacco use
A'chitectu'e CscallopedD. colo' C%N0D. consistency Cfib'otic ma!/ ant/D. su'face te!tu'e CsmoothD.
shape papillae Cblunted ma!/ ant/D. 'ecession &mm R&4
?ene'ali5ed bleeding in ma!/ Q mand/ ante'io' and poste'io' = 1/1&4
"ild ho'i5ontal bone loss = 00 Q 0#
!ental Chartin$
R 1. 1+. 11. Q (& = >!t'acted. R( lingual occlusal metallic 'esto'ation. R+ Q R11 att'ition. R14
lingual metallic 'esto'ation
R1, Q R1E facial metallic 'esto'ation. R&&-&1 att'ition. R& linguo<e'ted. R&+ to'so<e'ted to the
mesial. R&1 to'so<e'ted to the distal
R(0 occlusal facial metallic 'esto'ation Q mesial )$#
.adio$raphs
"ild ho'i5ontal bone loss 00 0#
Pe'iodontal case &
Gingival in+ammation2 generali3ed papillar# and marginal
Other Findin$s
None/
Chart
of
Patient
Needs
Prolem !tiolog
y
Positive
"ndings that
correlate #ith
the $rolem
Contriuting
or
$redis$osing
factors
Patient
!ducation
To$ics
Treatment O$tions and
Preventive Thera$ies
4riorit#
4laque
-
)acteria
-4oor
56
-plaque score
1.7
-"leeding score
1.1(-
-to"acco use
-calculus
-not
+ossing7"rushin
g enough
- slight
generali3ed
"io8lm
-to"acco
-calculus
-poor oral care
-not
+ossing7"rushi
ng enough
-medications
-de8ne plaque
-teach and
demonstrate
proper
"rushing
technique
-+ossing
-&erostomia
-alcohol free mouth rinse
-scale7plaque free
-home 9l(
-soft "ristle tooth"rush
-tongue "rushing
4riorit#
4eriodontitis
-
)acteri
a
-4oor
56
-4erio case t#pe
(
-plaque score
1.7
-"leeding
score1.1(-
-8"rotic "lunted
gingiva
-to"acco use
-calculus
-not
+ossing7"rushin
g enough
-poor oral care
- gingival
in+ammation
-to"acco use
-poor oral
care.
-calculus
-medications
causing dr#
mouth
-de8ne
periodontitis
-demonstrate
proper
+ossing
technique.
-e1ects of
to"acco use
-discuss the
outcome if
disease is not
treated
-sho! pictures
for m# patient
to "etter
understand
periodontitis
-scale7plaque free
-alcohol free mouth rinse.
-9l( treatment
-home 9l(
-soft "ristle tooth"rush
-+ossing
4riorit#
To"acco :se
-6a"it
-'tress
-4laque 'core
1.7
-4oor "leeding
score 1.1(-
-;alculus
- 8"rotic
gingiva
-calculus
-poor 56
-papillar#0
marginal
gingival
in+ammation
-perio case (
-e1ects
to"acco has
on oral health
-self e&am
techniques to
notice
changes in
-e1ects to"acco has on oral
health
-self-e&ams
-9l( treatment
-home 9l(
-scale7plaque free
-alcohol free mouth rinse
- staining -not
"rushing7+ossi
ng enough
-tooth staining
-halitosis
the oral cavit#
-
"rushing7+ossi
ng
-tongue
"rushing.
-anti"acterial
mouth rinse.
-information sheets
-videos
-changes side he dips on