Date: 10/22/2016 DMACC

Student Name: Shalene Bedwell Dental Hygiene

Patient Name: Glen
DOB: Treatment Plan
Medical History & Medications: ASA Physical Status Dental History: Occlusion:
No medications, diseases or conditions; Classification: The pt visited the dentist regularly as a bilateral Class 1
hay fever allergies Class 1 child and started to tapper off
throughout high school. Pt stopped
going to the dentist once he became self
employed aroung age 20. Pt has had
SRP done in the past but did not keep
follow up appointments. Pt has
restorations on teeth #'s
2,3,4,5,14,15,18,19,20, 30, & 31.Pt
states they only go to the dentist when
something bothers them but doesnt go
for cleanings.
Developmental Abnormalities & Defects: Restorative Problems: Other: Radiographic Evidence:
N/A Pt has recurent decay around a N/A FMX exposed at DMACC
deteriorating amalgum on the on ; few areas of
distal of # 2. readiographic calculus present.

Risk Factors are as follows (be specific).

1. Systemic Health: No 3. Caries Yes, distal of #2
CVD: No Sugar Intake: High
Diabetes Mellitus: No Streptococcus Mutans Count: mod
Respiratory Disease: No Plaque-Removal Ability: Normal with now limitations,
Generalized ineffective plaque
removal of whole mouth.
Osteoporosis: No Socioeconomic Status: Middle to high
Preterm Low Birth Weight: No Plaque Retentive Factors: Tight contacts but not crowded
Behavioral Status: Pt shows little interest in oral Fluoride History: Pt had access to fluoride as a
care, doesnt intend to keep child. Pt still has access to
regular apt after having SRP flouride water. He has not has a
done. professional flouride tx since his
last cleaning which was bout ten
years ago.

1
 Psychosocial Status: Normal Past & Present Caries Activity: Present caries activity on the
distal of #2. Pt past Caries activity
on occlusals of teeth #'s
2,3,4,5,14,15,18,19,20,31,&31.
Medication Considerations: None Other:
Other: N/A
4. Periodontal Disease: Localized Moderate periodontitis
and slight gingivitis.
2. Oral & Pharyngeal Cancer: No (host environmental risk factors/indicators)
Tobacco Use: No Previous History of Disease: Previously has been treated with
SRP 10 years ago.
Race: Caucasian Classification of Disease(s): Generalized moderate
Periodontitis
Alcohol Use None Clinical Attachment Loss: Generalized areas of
Sun Exposure: High, works and spends most Stress Factors
of his time outdoors
Pathology: None PHP: 3.4
Other: N/A PBI: 6.5%
Deposits Classification: V
Bacterial Pathogens: S. Mutans and Lactobaccilli;
probable Treponema denticola
and Porphyromonas gingivalis
Tobacco Use: No
Glycemic Control N/A
Inherited Risk N/A
Other:

2
Date: 10/22/2016
Student Name: Shalene Bedwell
Patient Name: Glen
DOB:

Diagnostic Decision Making

Eight Human Needs Related to Oral Health & Disease
Assessment (check signs and symptoms present)
1. Wholesome Facial Image 5. Freedom from Head and Neck Pain
Teeth Gingiva Facial Profile Extra-/intra-oral pain or sensitivity
Breath Other: Other:

2. Freedom from Anziety/Stress 6. Biologically Sound & Functional Dentition

Reports or Displays: Reports difficulty in chewing
Anxiety about proximity of clinician confidentiality or previous Presents with:
dental experience. Defective restorations Ill-fitting dentures, appliances
Oral Habits Substance Abuse Teeth with signs of disease Abrasion erosion
Missing teeth Rampant caries
Concern about: Other:
Infection control, fluoride therapy, fluoridation, mercury toxicity

3. Skin & Muccous Membrane Integrity of Head & Neck 7. Responsibility for Oral Health
Extra/intra-oral lesion Pockets greater than 4mm Plaque and calculus present
Swelling Attachment loss greater than 4mm Inadequate parental supervision of oral health care
Gingival inflammation Xerostomia No dental exam within the last 2 years
Bleeding on probing Other: Other:

4. Protection from Health Risks 8. Conceptualization & Understanding

BP outside of normal limits Need for prophylactic antibiotics Has questions about DH care and/or oral disease
Potential for injury Risk Factors Other:
Other:

3
4
Date: 10/22/2016
Student Name: Shalene Bedwell
Patient Name: Glen
DOB:

1. Initial Review Statement (chief concern, patient wants and expectations):

Glen is a 44 year old male who is seeking a dental cleaning. He has not been to his dentist for a cleaning for about ten years. Glen knows he should
be getting regular cleanings but doesn't carry dental insurance and is very busy running his machanical contracting business. Glen did admit he
drinks a lot of gatorade, pop, energy drinks, and sweet tea through out the day because his mouth feels dry. Upon the visit today the pt had no idea
ifhe had any current cavities but states he wouldnt be surprised if he did have any. He brushes two times a day but only flosses when he eats corn or
something that gets stuck in his teeth. Glen did express concern about local anestetic due to past dental experiences.The patient is not experiencing
any pain at this time.

2. Hypotheses (differential diagnosis):

Gingivittis
Periodontal disease
Decay
Halitosis
xerostomia
lack of understanding etiology
secondary infection
dental anxiety
bleeding on probing
heavy calculus
moderate plaque
lack of adequate home care
may not understand the need for dental treatment/recare appointments
may be non compliant with appointments
skin cancer

3. Inquiry Strategy:
php
pbi
FMX
nutritional counceling
perio refferal
SRP
ChX rinse
Carries Screaning
5
FMP
intra oral photos
6 week re eval
Fl treatment
edu on decay
Assesment
diagnodent for tooth #2
oral hygiene instruction
review Health history
review dental history
CHX mouth rinse
extra and intraoral exam
hard tissue charting and exam
deposit classification
Anesthetic
Cavitron
3 month SPM
Perscription CHX
Hand instruments
Follow up questions related to HH and dental History
consultation
refferal to perio office
Prophy
Floss

6
Date: 10/22/2016
Student Name: Shalene Bedwell
Patient Name: Glen
DOB:
4. Dental Hygiene Diagnosis (list the human need not met, then be specific about the etiology & signs & symptoms evidencing a defect):
Unmet Human Need
Wholesome Facial Image - Breath
Freedom from Anxiety/Stress- Anxiety about
proximity of clinician confidentiality or previous
dental experience
Freedom from Anxiety/ Stress- Oral Habits
Skin and Muccous Membrane Integrity of head
and Neck- Gingival inflammation
Skin and muccous Membrane Integrity of head
and Neck- Bleeding on probing
Skin and muccous membrane integrity of head and -Lack of routine dental care
neck- Pockets greater thatn 4mm
Skin and muccous Membrane Integrity of head
and Neck- Xerostomia
Etiology Signs & Symptoms
-Lack of adequate home care Upon Assessment hygienest noticed mal odor.
-lack of dental knowledge- may not know to brush
tongue
-Bacteria and lack of rutine dental care
-lack of dental knowledge Pt states they are nervouse about LA because of
-Negative past dental experiences past experiences.
-Lack of dental knowledge Pt reports drinking many sugary drinks through
-Sipping on cariogenic substances throughout the out the day
day.
- lack of understanding of the negative effects of
sipping on cariogenic drinks has on risks for
developing cavities.
-Lack of adequate home care Enlarged interdental papilla
-Generalized full mouth plaque/calculus Erythematous gingival tissue
accumulation
-Probable ineffective toothbrushing technique
causing inflamatory process
-Lack of dental knowledge- plaaque that is not
disrupted causes inflammation
-Lack of routine dental care
-Lack of routine dental care A PBI score of 6.5%
-Lack of adequate home care
-lack of dental knowlege
Generalized areas of 4 and 5 mm probing depths
-Lack of adequate home care specifically in posterior region
-Lack of nutrient dense diet and exercise Localized areas of 6mm probing depths
-lack of proper nutrition Pt reports dry mouth
7
Potection from Health Risks- potential for injury
Biologically Sound and Functional Dentition-
Defective restoration
Biologically sound and Funtional Dentition- Teeth
with signs of disease
Responsibility for Oral Health- Plaque and
calculus present
- Lack on dental knowledge
Conceptualization and understanding - has
questions about DH care and/or oral disease
9
-Pt uses tall ladders, heavy machinery and many Pt states their job is very physical
dangerous tools on an every day basis. Pt reports being outside in the elements a lot-
- Excessive exposure to sun potential for skin cancer.
- Possible iatrogenic cause During Assessment clinician evaluated a defectiva
- Possible life spand of denal material amalgum on the distal of #2
- Possible high acidic oral environment due to
freaquent sipping on carriogenic drinks throughout
the day
-Lack of routine dental care Carries on tooth # 2
-Lack of adequate home care Evident periodontal disease and gingivitis
-lack of dental knowledge pocket depths of greater than 4mm
-Ineffecive plaque removal
- Presents of lactobaccilli and strep mutans in the
oral cavity
- Possible high acidic oral environment due to
freaquent sipping on carriogenic drinks throughout
the day
-Lack of routine dental care PHP score of 3.4
-Lack of adequate home care Pt is a class 5 Deposit
-lack of dental knowledge
-Ineffecive plaque removal
-Lack of nutritional knowledge
-Lack of balanced diet
Pt reports no dental exams in the last 10 years.
-Lack of routine dental care Pt reports only going to the DDS when in pain or
- Negative past dental experiences concerned about a cavity
- Lack of motivation to shheduling appointments
-Lack of dental knoledge Pt lacks understanding about DH care and how
seriouse periodontal disease is.

Date: 10/22/2016
Student Name: Shalene Bedwell
Patient Name: Glen
DOB:
Apt #: 1 (UR SRP)
Date: 10/22/2016
Time Req: 1.5 hr
Jointly Determined Treatment Plan
Patient Goals
1. Pt will sign consent and hippa
forms for treatment.
2. Pt will understands why it is
important to be honest on health
history.
3. Pt will tell me if they have a CC.
4. Pt will show that he understands
why vital signs must be taken before
receiving dental treatment
5. Pt will allow me to preform all
parts of the pt assesment and
treatment, including; Reviewing HH,
taking BP and P, rinising with CHX
before tx, Cancer screening, EIE and
HTC, Perio assesment, probing,
disclosing, UR quad debrd.
6. Pt will understand the importance
of each component of the dental
assessment and dental treatment
procedure including; Reviewing HH,
taking BP and P, rinsing with CHX ,
Cancer screening, EIE, HTC,
probing, PBI, PHP, Occlusion
classification, perio classification,
deposit recognition
7.After I explain how BASS
brushing tq is bennificial for oral
hygiene and demo BASS tq. Pt will
demonstrate back to me tq, and
explain how BASS tq is bennificial
for their oral health.
8. Pt will show that he understands
10
Educations and Treatment Evaluation
(Target etiologies) (goal met, partially met or unmet)
1. Obtain pt consent and hippa forms, 1. Pt signed consent and hippa forms
verify it is completed, put in pt's for tx (GOAL MET)
chart 2. Pt showed that he understood the
2. Review pt's health history and purpose of a completed health
explain to pt the purpose of a history and why it is important to be
completed health history and why it honest on it. (GOAL MET)
is important. 3. Pt does not report a chief
3. Ask pt if anything is bothering complaint (GOAL MET)
them about or within their oral 4. Pt showed that he understood why
cavity. Record CC in notes and vital signs must be taken before
address throughout the apt. receiving dental treatment (GOAL
4.Take vital signs and explain why MET)
vital signs must be taken before 5. Pt allowed me to preform all parts
receiving dental treatment then of the pt assesment and treatment for
record in the pt's chart todays apt. including; Reviewing
5. Preform all parts of the assessment HH, taking BP and P, rinising with
and tx plan that is intended fot this CHX before tx, Cancer screening,
apt. EIE and HTC, Perio assesment,
6. Explain the importance of each probing, disclosing, UR debrd.
component of the dental assessment (GOAL MET)
and dental treatment procedure and 6.Pt showed that he understood the
anser any questions the pt may have. impportance of each component of
the dental assessmetn and dental tx
for this apt including, reiewing HH,
taking BP and P, rinsing with CHX ,
cancer svreening , EIE, HTC<
7. Explain and demo BASS tq to pt probing, PBI, PHP, Occlusion
and explain how this tq is bennicicial cassification, perio classification, and
for them and ask pt to demo BASS tq deposit recognition.(GOAL MET)
and ask them to explain in their own 7.Pt explained how BASS tq is
words how this tq is bennificial for bennificial for their oral health and
their oral health. demonstrated back to me how to
the purpose of having and instructor
perform a full mouth examination
9. Pt will consent to the instructor
performing the examination
10. Pt will show that he understands
any findings by the instructor from
the examination
11.Pt will show that he understands
his personal treatment plan.
12. Pt will show that he understands
the benefits of having radiographs
exposed, and will give consent to
have them exposed.
13. Pt will cooperate while
radiographs are being exposed
14. Pt will understands the benefits
of having intraoral photographs
taken, and will give consent to have
them taken
15. Pt will follow directions and
cooperate while intraoral
photographs are taken
16. Pt will understand what the DDS
confirms about his radiographs and
resterations that may need to be fixed
or redone.
17. Pt will understands the
recommened treatment, re-evaluation
and 3 month recare schedule.
11
8. Explain to pt the purpose of
having and instructor preform a Full
mouth examination.
9. Have the instructor preform the
examination.
10.Discuss with the instructror and
the pt any findings during the
examination.
11. Explain tx plan to pt and answer
any questions the pt may have about
the tx plan.
12. Explain to pt the importance of
having up to date x-rays. Expose x-
rays.
13. Explain the procedure of taking
x-rays and tell the pt what is needed
of them.
14. Explain the bennifits of having
intraoral photographs taken and take
the photographs.
15. Explain the procedure of taking
intraoral photographs and tellt the pt
what is needed of them
16.Explain what the DDS confirms
about the pt's radiographs. Assist the
DDS in writing out a refferal for the
pt to get his restoration lokked at by
his reg DDS.
17. Explain to the pt the
recommended tx, re-evaluation and 3
month recare schedule
perform the BASS tq. (GOAL MET)
8. Pt showed that he understood the
purpose of having an instructor
perform a FM examination. (GOAL
MET)
9. Pt consented to the instructor
performing the examination (GOAL
MET)
10. Pt showed that he understood any
findings from the instructor during
the examination (GOAL MET)
11. Pt showed that he understood his
personal tx plan and my plan of
action. (GOAL MET)
12. Pt showed that he undrstood the
benefits of having x rays exposed
and gave consent to having them
taken. (GOAL MET)
13. Pt showed that he understood
directions and cooperated while
radiographs where being exposed.
(GOAL MET)
14. Pt showed that he understood the
benefits of having intraoral
photographs taken and gave consent
to having them taken (GOAL MET)
15. Pt showed that he understood the
directions and cooperated while
intraoral photographs were taken
(GOAL MET)
16. Pt showed that he understood
what the DDS confirmed about his
radiographs, and reported that he was
going to use the refferal and go to his
DDS and get his defective restoration
and possible recurrent decay looked
at. (GOAL PARTIALLY MET)
17. Pt showed that he understood the
recommended treatment, re-

18. Pt will understand how many apt
this tx plan will require, what is
expected of him, and an estamate of
how much the tx plan will cost.
19. Pt will understand what the most
likely outcomes will be with or
without the tx.
20. Pt will agree to attend all future
apt and allow all tx to be preformed.
21. Pt will understand what the
cavitron is and how its use will be
bennificial for his oral conditions.
22. Pt will allow me to perform SRP
on the UR quadrant with cavitron
and hand instruments.
23. Pt will inform me of any
sensitivity while having SRP
preformed.
24. Pt will understand they can talk
about any concerns or ask questions
about receiving LA to releave any
dental anxiety.
25. Pt will allow me to admin local
anesthetic if needed.
26. Pt will understand and agree to
follow all post-op instructions.
Apt #: 2 (LR SRP) 1. Pt will sign consent and hippa
Date: 11/10/16 forms for treatment.
Time Req: 1hr 2. Pt will understands why it is
important to be honest on health
history.
12
evaluation and 3 month recare
schedule (GOAL MET)
18.Explain to pt what the outcomes 18. Pt showed that he understood
may be with or without tx. how many apt this tx plan will
19. explain to pt that a FM SRP can require, what is expected of him, and
only be accomplished through a the extamate of how much this tx
series of apts. plan will cost.
20. Explain to pt that they are 19. Pt showed that he understood
expecter to attend all future apt and what the likely outsomes would be if
allow all tx to be preformed. he were to choose to go with the tx
21. explain to pt what cavitron is and plan or if he would choose to go
how it will bennifit their oral withouth tx. (GOAL MET)
condition. 20. Pt reported they planned on
22. Preform SRP on UR with attending all future apts and allow all
cavitron and hand instruments. tx to be preformed. (GOAL MET)
23. Ask pt if they are comfortable 21. Pt showed that he understood
and encourage pt to allow me to what the cvitron was and how its use
know if there is any sensitivity. would be bennificial for his current
24. explain to pt about LA and oral conditions. (GOAL MET)
answer any questions they have 22. Pt allowed me to preform SRP on
about LA. the UR quadrant with cavitron and
25. admin local anesthetic if needed. hand instruments. (GOAL MET)
26. Explain to pt post-op instructions 23.. Pt stated he was experiencing
and clarify any details if needed. slight sensitivity (GOAL MET)
24. Pt talked about concerns about
LA. (GOAL MET)
25. PT reported he was experiencing
slight sensitivity but didnt want LA
at this apt but is open to receiving
LA at future apt if he felt the
discomfort needed to be handled.
(GOAL MET)
26. Pt agreed to follow all post-op
instructions (GOAL MET)
1. Obtain pt consent and hippa forms, 1. Future appointment-goal unmet
verify it is completed, put in pt's
chart
2. Review pt's health history and 2. Future appointment-goal unmet
explain to pt the purpose of a
3. Pt will show that he understands completed health history and why it
why vital signs must be taken before is important.
receiving dental treatment 3.Take vital signs and explain why 3. Future appointment-goal unmet
4. Pt will allow me to preform all vital signs must be taken before
parts of the pt assesment and receiving dental treatment then
treatment, including; Reviewing HH, record in the pt's chart
taking BP and P, rinising with CHX 4. Preform all parts of the assessment 4. Future appointment-goal unmet
before tx, Cancer screening, EIE and and tx plan that is intended fot this
HTC, Perio assesment, disclosing, apt.
LR quad debrd.
5. Pt will understand the importance
of each component of the dental 5. Explain the importance of each 5. Future appointment-goal unmet
assessment and dental treatment component of the dental assessment
procedure including; Reviewing HH, and dental treatment procedure and
taking BP and P, rinsing with CHX , answer any questions the pt may
Cancer screening, EIE, HTC, have.
probing, PBI, PHP, Occlusion 6. Ask pt if they have been using the 6. Future appointment-goal unmet
classification, perio classification, BASS tq discussed at our last visit. If
deposit recognition. so move on to new pt ed if not re
6. Pt will tell me he has been using explain the BASS tq and its
the BASS tq while brushing since the importance for the pts oral health and
last visit. try to see why the pt is having issues
adapting this new tq into his daily
7. Pt's tissue on the UR will show brushing rutiene.
improvement in health since last 7. Evaluate the UR tissue for 7. Future appointment-goal unmet
visit. improvement in health.
8. After I explain how "C" tq flossing 8. Explain how C tq flossing is 8. Future appointment-goal unmet
1x a day is bennificial and demo it bennificial for pts oral health and
for the pt; the pt will be able to demo it for pt. ask pt to demo C tq
demonstrate "C" tq flossing and flossing back and ask pt to explain in
explain how this will benefit their their own words how C tq is
oral hygiene. bennificial for them.
9.Pt will understand the etiology of 9. Explain the etiology of plaque and
plaque and calc build up and how calc build up and how it is a risk 9. Future appointment-goal unmet
this plays into gingivitis and perio. factior for gingivitis and perio.
10. Pt will understand the negative 10. Explain to pt the neg. effects
effects periodontitis has on the teeth periodontitis has on the teetha dn 10. Future appointment-goal unmet
and supporting bone. supporting bone.
11. Pt will allow me to perform SRP 11. Preform SRP on LR with 11. Future appointment-goal unmet
13
 on the LR quadrant with cavitron and
hand instruments.
12. Pt will inform me of any
sensitivity while having SRP
preformed.
13. Pt will allow me to admin local
anesthetic if needed.
14. Pt will understand and agree to
follow all post-op instructions.
Apt #: 3 (UL SRP) 1. Pt will sign consent and hippa
Date: 11/21/16 forms for treatment.
Time Req: 1 2. Pt will understands why it is
important to be honest on health
history.
3. Pt will show that he understands
why vital signs must be taken before
receiving dental treatment
4. Pt will allow me to preform all
parts of the pt assesment and
treatment, including; Reviewing HH,
taking BP and P, rinising with CHX
before tx, Cancer screening, EIE and
HTC, Perio assesment, disclosing,
UL quad debrd.
5. Pt will understand the importance
of each component of the dental
assessment and dental treatment
procedure including; Reviewing HH,
taking BP and P, rinsing with CHX ,
Cancer screening, EIE, HTC,
probing, PBI, PHP, Occlusion
classification, perio classification,
deposit recognition
6. Pt will tell me they have been
preforming the "C" flossing tq at
least one time a day since the last
visit and are continuing to use the
BASS tq for brushing.
14
cavitron and hand instruments.
12. Ask pt if they are comfortable 12. Future appointment-goal unmet
and encourage pt to allow me to
know if there is any sensitivity.
13. admin local anesthetic if needed. 13. Future appointment-goal unmet
14. Explain to pt post-op 14. Future appointment- goal unmet
instructions.
1. Obtain pt consent and hippa forms, 1. Future appointment-goal unmet
verify it is completed, put in pt's
chart
2. Review pt's health history and 2. Future appointment-goal unmet
explain to pt the purpose of a
completed health history and why it
is important.
3.Take vital signs and explain why 3. Future appointment-goal unmet
vital signs must be taken before
receiving dental treatment then
record in the pt's chart
4. Preform all parts of the assessment 4. Future appointment-goal unmet
and tx plan that is intended fot this
apt.
5. Explain the importance of each 5. Future appointment-goal unmet
component of the dental assessment
and dental treatment procedure and
answer any questions the pt may
have.
6.Ask pt if they have been 6. Future appointment-goal unmet
preforming the "C" tq at least 1x a
day since the last visit and if they are
continuing to use the BASS tq for
brushing.
 7. pt's tissue on the UR and LR will
show healthy improvement since 7. Evaluate the UR and LR tissue for 7. Future appointment-goal unmet
last visit. improvement in health.

8. pt will understand his occupation

puts him at a high health risk. 8. Explain since pts occupation 8. Future appointment-goal unmet
involves having high exposure to the
direct sun that this puts him at a
higher health risk for possible skin
cancer. Educate pt on using sun
9. Pt will understand how his screen to reduce their health risk.
frequent sipping on of sugary/acidic 9. Explain to pt how sugary/acidic 9. Future appointment-goal unmet
drinks throughout the day has a drinks throught the day can increase
negative effect on his oral health and their suseptability to future decay.
that these drinks should be drank Explain to pt how it isnt so much the
with meals not sipped on all day quantity of sugary acidic drinks they
long. injest but the frequincy. Suggest the
pt try to drink those types of drinks at
meal times or drinking all at once
10. Pt will allow me to perform SRP rather than sipping throught the day.
on the UL quadrant with cavitron and 10.Preform SRP on UL with cavitron 10. Future appointment-goal unmet
hand instruments. and hand instruments.
11. Pt will inform me of any
sensitivity while having SRP 11. Ask pt if they are comfortable 11. Future appointment-goal unmet
preformed. and encourage pt to allow me to
12. Pt will allow me to admin local know if there is any sensitivity.
anesthetic if needed. 12. Admin LA if needed. 12. Future appointment-goal unmet
13. Pt will understand and agree to
follow all post-op instructions. 13. Explain to pt post-op 13. Future appointment -goal unmet
instructions.
Apt #: 4 (LL SRP) 1. Pt will sign consent and hippa 1. Obtain pt consent and hippa forms, 1. Future appointment-goal
Date: 12/01/16 forms for treatment. verify it is completed, put in pt's unmet
Time Req: 1hr 2. Pt will understands why it is chart
important to be honest on health 2. Review pt's health history and 2. Future appointment-goal unmet
history. explain to pt the purpose of a
3. Pt will show that he understands completed health history and why it
why vital signs must be taken before is important.
receiving dental treatment 3.Take vital signs and explain why 3. Future appointment-goal unmet
4. Pt will allow me to preform all vital signs must be taken before
15
parts of the pt assesment and
treatment, including; Reviewing HH,
taking BP and P, rinising with CHX
before tx, Cancer screening, EIE and
HTC, Perio assesment, disclosing,
LL quad debrd.
5. Pt will understand the importance
of each component of the dental
assessment and dental treatment
procedure including; Reviewing HH,
taking BP and P, rinsing with CHX ,
Cancer screening, EIE, HTC,
probing, PBI, PHP, Occlusion
classification, perio classification,
deposit recognition
6. Pt will state they are drinking their
sugary acidic drinks at meal times
and not constantly sipping on them
throughout the day.
7.Pt will understand how to use a
tongue brush and the importance of
brushing their tongue daily to disrupt
bacteria that causes bad breaath.
8. Pt's tissue on the UL will show
improvement in health.
9. Pt will allow me to perform SRP
on the LL quadrant with cavitron and
hand instruments.
10. Pt will inform me of any
sensitivity while having SRP
preformed.
11. Pt will allow me to admin local
anesthetic if needed.
12. Pt will understand and agree to
follow all post-op instructions
13. Pt will understand the importance
of the 6 wk re-eval and agree too
attend.
16
receiving dental treatment then
record in the pt's chart
4. Preform all parts of the assessment 4. Future appointment-goal unmet
and tx plan that is intended fot this
apt.
5. Explain the importance of each 5. Future appointment-goal unmet
component of the dental assessment
and dental treatment procedure and
answer any questions the pt may
have.
6. Ask pt if they have been limiting 6. Future appointment-goal unmet
these sugary/acidic drinks to meal
times or drinking in one sitting rather
than sipping on them all day long.
7.Explain to pt how to properly use 7. Future appointment-goal unmet
a tongue brush and educate them on
the importance of brushing their
tongue daily.
8. Evaluate the UL tissue for signs of 8. Future appointment-goal unmet
improvement in health.
9. Preform SRP on LL with cavitron 9. Future appointment-goal unmet
and hand instruments.
10. Ask pt if they are comfortable 10. Future appointment-goal unmet
and encourage pt to allow me to
know if there is any sensitivity.
11. Admin local anesthetic if needed. 11. Future appointment-goal unmet
12. Explain to pt post-op 12. Future appointment-goal
instructions. unmet
13. Explain to pt the importance of 13. Future appointment- goal unmet
the 6 wk re-eval and gather assurance
that they agree to attend. If they need

Apt #: 5 (6 wk re-eval) 1. Pt will sign consent and hippa
Date: 01/12/17 forms for treatment.
Time Req: 1 hr 2. Pt will understands why it is
important to be honest on health
history.
3. Pt will show that he understands
why vital signs must be taken before
receiving dental treatment
4. Pt will allow me to preform all
parts of the pt assesment and
treatment, including; Reviewing HH,
taking BP and P, rinising with CHX
before tx, Cancer screening, EIE and
HTC, Perio assesment, probing,
disclosing, FM debrd, prophy, Floss,
Fl varn.
5. Pt will understand the importance
of each component of the dental
assessment and dental treatment
procedure including; Reviewing HH,
taking BP and P, rinsing with CHX ,
Cancer screening, EIE, HTC,
probing, PBI, PHP, Occlusion
classification, perio classification,
deposit recognition
6. Pt will have lowered his PBI from
6.5% to 2%.
7. Pt will have reduced his PHP from
3.4 to 2.
8. Pt will confirm that he has been
using the "C" flossing tq 1x daily and
has been using the bass tq when
brushing 2x a day.
9. Pt will demo" C" flossing tq and
17
encouragment remind them that at
the 6 wk re-eval is when we are
planning on polishing their teeth.
1. Obtain pt consent and hippa forms, 1. Future appointment-goal unmet
verify it is completed, put in pt's
chart
2. Review pt's health history and 2. Future appointment-goal unmet
explain to pt the purpose of a
completed health history and why it
is important.
3.Take vital signs and explain why 3. Future appointment-goal unmet
vital signs must be taken before
receiving dental treatment then
record in the pt's chart
4. Preform all parts of the assessment 4. Future appointment-goal unmet
and tx plan that is intended fot this
apt.
5. Explain the importance of each 5. Future appointment-goal unmet
component of the dental assessment
and dental treatment procedure and
answer any questions the pt may
have.
6. Full Mouth Periodontal Probing. 6. Future appointment-goal unmet
Calculate PBI % and record in pt's
chart
7. PHP- Disclose pt's teeth, calculate 7. Future appointment-goal unmet
PHP and record in pt's chart. Review
any areas that disclose.
8. Ask pt if he's still flossing 1x a day 8. Future appointment-goal unmet
at home using "C" shape floss tq and
brushing 2x a day using the BASS
toothbrushig tq.
 bass brushing tq
10. Pt will confirm that his sugary
acidic beverage drinking habits are
limited to with meals and/or only
during short periods of time
throughout the day
11. Pt will show that he understands
how his tissues are looking and
healing.
12. Pt will show that he understands
the need for a 3 month recare
schedule.
13. Pt will consent to me polishing
his teeth and allow me to polish his
teeth.
14. Pt will consent to me flossing his
teeth and allow me to floss his teeth.
15. Pt will consent to getting a
fluoride varnish treatment, allow me
to apply fluoride varnish, and will
show that he understands all post-op
instructions.
16. Pt will understand how important
it is to have regular scheduled
cleanings for preserving dentition
and preventing future cavities.
17. Pt will agree to attend in 3
months for his first SPM appt
Apt #:
Date:
Time Req:
Apt #:
Date:
Time Req:
Apt #:
Date:
Time Req:
18
9. Ask pt to demo "C' tq and BASS 9. Future appointment-goal unmet
tq. If needed demo tq and re-explain
any aries of concern with their tq.
10. Confirm with pt that his 10. Future appointment-goal unmet
sugary/acidic drinking habits are still
limited to with meals or during short
periods of time throughout the day
11. Preform gingival tissue 11. Future appointment-goal unmet
asssessment and explain/ discuss
with pt how his tissues are looking
and healing and educate the pt on
areas that need extra attention during
home care.
12.Explain and discuss with pt the 12. Future appointment-goal
need for a 3 month recare schedule unmet
13. Use selective polishing tq and 13. Future appointment-goal
also polish all teeth that disclosed; unmet
use hand instruments if there are any
areas of heavy stain that the
polishing cup may have missed.
14. Floss the pt's teeth. 14. Future appointment- goal unmet
15. Apply fluoride varnish and 15. Future appointment-goal unmet
explain post-op instructions.
16. Explain to pt the importance of 16. Future appointment- goal unmet
having regular scheduled cleanings
for preserving dentition and
preventing future decay.
17. Schedule pt for 3 month SPM 17. Future appointment
appt.