Patient Specific Dental Hygiene Care Plan

Patient Name XX

Age _20___

Student Name Kayla Garcia

Gender: M F
Date: 03-03-16

Chief Complaint: Cleaning

Assessment Findings
Medical History
#92- Gums bleed occasionally when
brushing/flossing.
#97- Sometimes has cavities at dental checkups.

Social and Dental History

-Medium toothbrush
-Brushes 2x a day (am/pm)
-Floss (at night)
-Rinse (every other day)
- No fluoride
-Plaque score- 0.33 Good
-Bleeding score 0.6%

Dental Examination
1. Localized ephelides
2. Scar on upper forehead & along border of
bottom lip

At Risk For
#92- gingivitis periodontitistooth loss
#97- Tooth sensitivity, tooth destruction, loss of
tooth

At Risk For
-Plaque
-Calculus
-Caries
-Continued gingivitis
-Periodontitis
-Recession
- Sensitivity

At Risk For
1. Skin cancer
2. None
3. Progression of blindness

3.
4.
5.
6.
7.
8.
9.

Corrective lenses- contacts for myopia

Submandibular lymphadenopathy, pea size
Bilateral linea alba
Plaque coated tongue- dorsal surface
Grinding w/ stress
Biofilm- slight, generalized
Tissues slightly red on ling. mand. post. molars
& mand. ant. linguals
10. Tissue Edematous/spongy
11. Surface texture smooth and shiny for areas
indicated red
12. Bleeding- #10
Periodontal Case Type: 1

4.
5.
6.
7.

Immobility, enlargement, cancer

Irritation
Bacteria, Infection
TMJ Problems, Soreness, Tenderness, Lock Jaw,
Muscle Tension, Limited opening, Abfraction,
Attrition
8-12. Gingivitis Periodontitis, tooth loss

Plaque Score: .33

Bleeding Score: _0.6%

Gingival Inflammation: Localized, marginal in mand. Post. Ant. linguals

Biofilm: Slight, Generalized
Biofilm Retentive Features/Predisposing Factors: Malpositioned tooth
Dental Hygiene Diagnosis
Problem

Etiology

1. Plaque

1. Results to calculusdemineralizationcaries

2. Gingivitis

2. Bleeding gums, halitosis, periodontal pockets,

gingivitis periodontitis. Gingivitis is reversible, if
caught soon enough. Periodontitis is irreversible, but
can be halted.

3. Fluoride (due to being caries prone- will discuss

caries along w/ this)

3. Fluoride effectively helps control and heal early

signs of tooth decay. Remineralizes

Planned Interventions
Clinical
Scaling hard

Education
1. Plaque
- Describe what it is (sticky deposits

Oral Hygiene Instruction

1. Plaque
- Brushing mechanically 2x a day

deposit
removal
Polishing soft
deposit removal
Fluoride application

of bacteria)
- What it looks like (sticky, clear
film, food debris)
- How to remove it
(brushing/flossing)
- What it causes (if left to harden it
becomes calculus. If not cleaned
then the gums will get irritated
which leads to gingivitis)
2. Gingivitis
- Describe what it is- inflammation
of gums (gingival tissue)
- What causes it ( accumulation of
plaque/bacteria biofilm releasing
substances that cause
inflammatory reaction as well as
smoking)
- How to remove it
(brushing/flossing)
- It is REVERSABLE but if left to
progress then it will turn into
periodontitis which IS NOT
reversible.
3. Fluoride / Caries
- What it is (Cavity, hole in tooth)
- What it looks like (brown sticky)
- How it is caused (when pH of
mouth is between 4.4-5.5 over a
long period of time)
- What it causes (demineralization
of enamel, can possibly
remineralize)
- Define fluoride (sodium fluoride or

2. Gingivitis
-Brushing mechanically 2x a day
-Flossing
-Professional cleaning every 6
months

3.
-

Fluoride / Caries
Brushing 2x a day
Flossing
Reduce snacks in between meals
so pH can return to normal
Drink water in between meals
Use of fluoride to help strengthen
teeth due to pt. being caries prone
Fluoride effectively helps control
and heal early signs of tooth decay

another fluoride-containing salt

added to water supplies or
toothpaste in order to reduce
tooth decay)
State what fluoride does, benefits
of it
Expected Outcomes

Goals
LTG 1: To reduce plaque score to .1 or less
STG: Define plaque

Evaluation Method
1. Take plaque score at every visit.
Ask questions about plaque and
recent brushing habits.

Time
Frame
1. By end
of 3rd
appoint.

STG: Define brushing (2x a day)

STG: Help brush with the correct brushing
method
LTG 2: Reverse gingivitis
STG: Define gingivitis
STG: Define flossing & demonstrate flossing (2x
a day)

2. Take new bleeding score/visual

inspection of gums for more or
less inflammation. Ask about
flossing habits, adjust if needed.

2. By end
of 3rd.
appoint.

STG: Reduce bleeding score by 0.1 each

appointment (until reach bleeding score of 0)
LTG 3: Daily use of Fluoride
STG: Define fluoride
STG: Educate on the benefits of fluoride
STG: Use of fluoride on a daily basis &

3. Check for caries

3. By end
of 3rd
appoint.

Prognosis
Good
Fair
Poor
Questionable
Hopeless

Explain your prognosis

Patient shows motivation to improve overall oral health.
Improvement on brushing and flossing method 2x daily. Is willing to
learn overall better oral hygiene. With proper education and
assistance, I think the patient and myself can work as a team to lower
plaque and bleeding score, reverse gingivitis & continue to restore
the teeth to help patient be less caries prone.
Appointment Plan

Appt
#
1

Plan for Treatment

Dental/Med History
Pre Rinse
Take Plaque/bleeding score
Patient Education
Scaled UR
Update Dental/Med History
Pre Rings
Take Plaque/bleeding score
Patient Education
Scaled UL

Update Dental/Med History

Pre-Rinse
Take Plaque/bleeding score
Patient Education
Scaled LR
Update Dental/Med History
Pre Rinse

Plan for Education, Counseling or Oral

Hygiene Instruction
Define plaque
Teach patient how to properly brush
Watch patient brush
Adjust/reeducate brushing if needed
Define gingivitis & disease progression if not
halted (periodontitis)
Teach patient how to floss
Watch patient floss
Adjust/reeducate flossing and/or anything from
previous session. Quick review of brushing from
previous appointment & ask if patient is able to
comply thus far
Define Caries/Fluoride
Teach patient about diet, pH levels, acid attacks
(pH 4.4-5.5 over a period of time)
Adjust/reeducation anything from previous session
Review previous appointment skills
Ask patient if she has any questions or concerns

Take Plaque/bleeding score

Patient Education
Scaled LL
Plaque Free
Fluoride Treatment
Referrals: None
Recall Interval: 6 months

Put patient on 6 month recall