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Patient Specific Dental Hygiene Care Plan

Patient Name: Age: 19 Gender: F

Student Name: Morgan Fowler Date: 2-5-17

Chief Complaint: cleaning

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

Social and Dental History At Risk For

Last dental visit- braces removed (2012) Calculus and plaque buildup, undiagnosed caries/ perio disease
Last radiographs- FMX (01-2017) None
Clenches/grinds jaws- stress TMJ problems, attrition
Caries Treatment, recurrent decay, nerve involvement, pain, tooth loss

Dental Examination At Risk For

Athletic body type None
Mesognathic profile None
Scattered ephilids-sun exposure Skin cancer
TMJ palpable on left side- no tenderness, no pain TMJ problems
Mandibular bilateral tori- developmental None
Grinds/ clenches- stress TMJ, attrition
Occlusion- Right-WNL, Left-tendency to class II None
Overbite- 5mm, Overjet- 4mm, mid-line shift- 2mm to the Malocclusion, excessive tooth wear
Scalloped architecture WNL None
Slightly red- mandibular lingual, facial anterior, lingual #3 Gingivitis
Edematous/spongy- mandibular lingual, facial anterior, lingual Gingivitis
Smooth and shiny texture- mandibular lingual, facial anterior, Gingivitis
lingual #3
Attached texture- stippled None
Margins/papilla/recession WNL None
Slight bleeding on D#14, D#18, L#25 Gingivitis
Caries D#14, watch D #31 Restorative care, recurrent decay
Impacted #1 #16 #17 #32 Surgery removal, infection, teeth shifting (orthodontic work)
Lingual retainer Increased plaque and calculus, gingival inflammation
Home care: medium brush, horizontal scrub (am), floss More plaque buildup, gingivitis, abrasion
sometimes, no rinse, Colgate paste, no fluoride, no aids
Calculus- Prophy class 3 Increased gingivitis, possible progression to periodontitis

Periodontal Case Type: 1 Plaque Score: 3.3 fair Bleeding Score:1.5

Gingival Inflammation: localized marginal facial anterior, mandibular lingual
Biofilm: slight generalized
Biofilm Retentive Features/Predisposing Factors: calculus, caries, medication, lingual retainer
Dental Hygiene Diagnosis
Problem Etiology
1. Caries Nutritional behavior habits, bacteria (mutans streptococci and
lactobacilli), poor home care
Certain bacteria that causes tooth decay and gum disease if not
removed regularly by brushing and flossing. Plaque uses sugars
2. Plaque/ calculus from food to produce acids that eat away the enamel.

Poor home care, develops when biofilm is left undisturbed on

3. Gingivitis the tooth, infrequent dental cleanings- excessive calculus
Buildup problem area, poor use of floss aids

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)
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) 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
STG: define plaque by next appointment

STG: demonstrate proper brushing by the end of todays


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
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.

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.

perio debridement on mandibular Define gingivitis, correctly demonstrate flossing, review

3 right and left, check plaque and brushing technique and appointment referral on carious
bleeding score- 2 hr. lesion

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

Referrals: DDS for restoration on caries

Recall Interval: 6 months