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Patient Specific Dental Hygiene Care Plan

Patient Name anonymous Age 20 Gender: M F

Student Name Marsha Tran Date 06 - 19 - 1996

Chief Complaint: helping out friend

Assessment Findings

Medical History At Risk For


Last physical in 2014-------------------------------------------------------- normal

Low Ogestrel------------------------------------------------------------------ gingival inflammation, dry socket if extracted

Terbinafine-------------------------------------------------------------------- semisupine chair position if GI effects occur; pts on


chronic drug therapy may rarely have symptoms of
blood dyscrasias includes infection, bleeding, and
poor healing

Albuterol----------------------------------------------------------------------- xerostomia; assess salivary flow as factor of caries,


perio, candidiasis; midday appts. & stress reduction
protocol; aware aspirin/ sulfate preservatives in
vasoconstriction asthma, asthmatic episodes

Tonsillectomy in 2014------------------------------------------------------ none

2 sinus surgeries in 2017-------------------------------------------------- none

Bronchitis in 2016----------------------------------------------------------- none

Asthma (low grade; inhaler only used in sports) ------------------- may cause xerostomia due to albuterol
Sinus problems -------------------------------------------------------------- none

Severe headaches/ migraines ------------------------------------------- grinding/ clenching teeth night; overworking tmj

Drinks alcoholic beverages 2 times a month------------------------ none

Social and Dental History At Risk For


Last dental visit in 6/ 2016----------------------------------------------- Gingivitis/perio

Sensitive teeth to cold ----------------------------------------------------- none

Grinding/ clenching at night -------------------------------------------- TMJ, leading to headaches

Dental Examination At Risk For


athletic------------------------------------------------------------------------ None

Mesognathic------------------------------------------------------------------ None

Scattered ephilids----------------------------------------------------------- Skin cancer

X shaped scar from birth control implant on left arm ---------- None

in scar on left hand near thumb------------------------------------- none

Scattered acne --------------------------------------------------------------- Bacteria

Dry lips on tissue------------------------------------------------------------- Xerostomia; possible infection

Tmj slight tenderness ---------------------------------------------------- grinding; headaches

Oropharynx: Tonsils/ Tonsillar crypt---------------------------------- tonsillectomy: there are no risk

Uvula cut off some during tonsillectomy ---------------------------- none


Grinding/ clenching--------------------------------------------------------- attrition; headaches; TMJ problems

Occlusal exam: class 1 on LT. & RT. Molar; LT. & RT. Canine ---- none

Overbite: WNL 2mm -------------------------------------------------------- none

Overjet: WNL 3mm ---------------------------------------------------------- none

Midline shift: 1 mm to right ----------------------------------------------- none

Slight biofilm generalized------------------------------------------------- caries/ gingivitis/ periodontitis

Generalized scalloped architecture------------------------------------- Gingivitis/perio

Surface texture (papillary & marginal): smooth-------------------- Gingivitis/perio

Surface texture (attached): stippled------------------------------------ Gingivitis/perio

Shape, papillae: normal (wnl)-------------------------------------------- none

Shape, margins: normal (wnl)-------------------------------------------- none

Bleeding points: generalized---------------------------------------------- periodontitis/ gingivitis

Pocket depths: #2-3, # 19, #30-31-------------------------------------- periodontitis/ gingivitis

Attrition: Mandibular anterior------------------------------------------ Increased risk of caries and dentin hypersensitivity

Caries: UL #13 D, #14 M --------------------------------------------------- Recurrent caries

Periodontal Case Type: 1 Plaque Score: 1.6 Bleeding Score: 10%

Gingival Inflammation: none


Biofilm: Slight Generalized
Biofilm Retentive Features/Predisposing Factors: calculus

Dental Hygiene Diagnosis


Problem Etiology

Bruxism (grinding and clenching)------------------------------------------ trauma


Plaque brushing------------------------------------------------------------ Poor brushing
Periodontitis Flossing *irreversible* -------------------------------- Not brushing/flossing, poor oral home care
Dry cracked lip tissue ------------------------------------------------------ Lack of moisture care, dry mouth, infection
Grinding------------------------------------------------------------------------- Developmental; muscle tension

Planned Interventions

Clinical Education Oral Hygiene Instruction


Plaque- is a soft white, sticky biofilm Brushing, good home care, and reduce plaque
substance on the teeth. Remove plaque by score.
Scaling hard deposit
brushing correctly. It causes gingivitis,
removal
periodontitis, and caries.

Polishing soft deposit Brushing, flossing, good home care, and


gingivitis- is a reversible inflammation of
removal antiseptic mouth rinse
the gingiva that bleeds easily, it is halted by
flossing and brushing. It leads to
periodontitis and bone loss.
Fluoride application
Bruxism is from grinding and clenching. It
can lead to attrition, and dentin Use mouth guard at night
hypersensitivity. Using a mouth guard will
halt the progression from getting worse.
Expected Outcomes

Goals Evaluation Method Time Frame


Plaque score
LTG 1: Patient will understand what plaque is. Reduce 1.
is lowered to
plaque score 1.6 to .5 by final appointment.
Ask patient about plaque .5 by final
STG: Patient defines plaque appointment
Teach correct brushing technique and watch
and
STG: Correctly demonstrate brushing by end of patient brush
maintained
todays appt
Record new plaque score each visit by recall
STG: Reduce plaque score by .4 each appt. & maintain visit 6
a score of .5 or lower by final/ recall appointment months.

LTG 2: Patient will understand what gingivitis is. Halt 2.


the progression of gingivitis and lower/maintaining
review patient about plaque
bleeding score to 0 by recall visit 6 months
teach proper flossing, and watch patient 6 months
STG: patient defines gingivitis
floss
STG: demonstrate how to floss by end of appointment
check bleeding scores and maintain by
STG: maintain and improve bleeding score to 0 by recall visit (6 months)
final/ recall visit
3.
LTG 3: reduce attrition from bruxism
review patient the definition of plaque, and
STG: patient define bruxism gingivitis

STG: ask patient what bruxism can cause and how to define bruxism and what can it cause 6 months
prevent the cause
Ask patient what they could use to help with
STG: educate patient on wearing a night guard at bruxism from progressing more attrition,
night and headache problems
Prognosis Explain your prognosis

Good Patient has a decent home health care, but the patient needs to be shown better flossing
techniques shown by clinician in order to reverse gingivitis to keep it from progressing.
Fair

Poor

Questionable

Hopeless

Appointment Plan

Appt Plan for Treatment Plan for Education, Counseling or Oral Hygiene
# Instruction
Periodebridement on UR & UL. Reduce plaque score from 1.6 to .5 by final appointment
1
Check plaque score (reduce .4)

Probe for bleeding score (reduce 3.3%)

Periodebridement on LL & LR Reverse gingivitis by flossing, brushing, and good home


2
Check plaque score (reduce .4) care
Probe for bleeding score (reduce 3.3%)

Polish, floss, & fluoride Advise patient to use mouth guards at night to prevent
3 the progression of attrition, and headache problems.
Check plaque score (reduce .4)

Probe for bleeding score (reduce 3.3%)

Referrals: To dentist for caries area on #13 Distal, #14 Mesial


Recall Interval: 6 months