PERIODONTAL CARE PLAN

Patient Name______ __________________Age____34____

Date of initial exam_________11/17/17_____________________ Date
completed________12/01/17__________

1. Medical History: (systemic conditions altering treatment, pre-medication, medical clearance) explain
steps to be taken to minimize or avoid occurrence, effect on dental hygiene diagnosis and/or care.

She does not take any medications or have any systemic diseases. She hasn’t had a physical checkup in a
long time so there might be some problems that are not yet diagnosed. These undiagnosed problems could
cause problems that could contribute to oral problems in the future.
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2. Dental History: (past dental disease, response to treatment, attitudes, dental I.Q., chief complaint,
present oral hygiene habits, effect on dental hygiene diagnosis and/or care)

Her chief complaint was wanting a cleaning and a checkup done to her. She has not been to the dentist in
7 years and her last visit was for a checkup. Her dentist explained she had caries but did not have the
money at that time to do the fillings. The multiple caries could attribute to the loss of tooth structure
resulting in an extraction of the tooth. This could contribute to furthering her periodontal disease.

3. Oral Examination: (lesions noted, facial form, habits and awareness, consultation)
Her has linea alba on bilateral on her buccal mucosa. Her tongue is pigmented, and she also has
anklyglossia. Her occlusion was a class 1 all around except for the right quadrant molars. She
was missing her first molar, so it could not be classified. She had an overjet and overbite of
4mm.
4. Periodontal Examination: (color, contour, texture, consistency, etc.)

a. Case Classification __4___ Periodontal Case Type____2__

b. Gingival Description:

App't 1: ___Her initial exam I saw a red color tissue on her mandibular anteriors on her
facial and lingual side. She had spongy tissue on the mandibular anterior and lingual. While
her margins were rolled on mandibular lingual and facial on the anteriors. Her surface texture
for her papillary and marginal were smooth and shiny localize to her mandibular anteriors on
either side. The initial examination done to her help me understand that she had some sort of
periodontal disease, which can contribute to more bone loss and/or tooth mobility. ______
App’t 2: Her second appt I saw an improvement on her plaque score and bleeding score. The
gingival on her anteriors were starting to show a healthy color with an improvement on the
shape of her papilla as well. However, the mandibular anteriors lingual and facial showed the
same texture. The mandibular molars in the right quadrant, also showed spongy red
consistency that wasn’t noted on her first appt. This indicated to me that there was a local
factor that was causing this problem. The texture on her gingiva indicated to me that although
her oral hygiene habits were improving, the removing of the local factor could improve the
health of her gingiva as well halt the progression of her disease.
App’3: Her final appt, I saw a drastic improvement on her gingival. Upon returning after
her cleaning, the areas which showed inflammation healed and her pocket depths went down.
The surface texture on her papilla and margins showed a healthy normal look. The only areas
where I found no changes was the distal of #31 because of the impaction of #32. This
impacted tooth could lead to some bacteria to colonize in that area, causing an increase in
inflammation as well as more bone loss in the future. This improvement of her gingival
indicated that periodontitis had halted at this point.
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c. Plaque Index: App’t 1___1.5 (fair)__ 2_1(good)____ 3__.8(good)

d. Gingival Index: Initial _.9 (good)_____ Final __.3 (good)__

e. Bleeding Index: App’t 1___6%__ 2__3%___ 3__1%__

f. Evaluation of Indices:
1. Initial___Her initial gingival index was a .9 which is good. Most of the areas of the teeth showed
a 1, which usually were in the interproximal areas. She was missing tooth number 30 so I used
#31 instead. She had moderate plaque on her anteriors which contributed to the inflammation of
her gingiva. I had trouble probing some areas of her teeth because of the location of calculus on
that area. Her had slight generalize bleeding, which indicated the progression of the periodontal
disease. ____________________________________________________________________
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2. Final____Her last gingival index was a .3 (good) which indicated that the areas that I found
higher pocket depth numbers went down. The removing of calculus and a better understanding
on how to take care of her teeth, was a contributor to improving of her gingiva. The plaque score
and bleeding score went down which improved her oral health in a great way.
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g. Periodontal Chart: (Record Baseline and First Re-evaluation data)
1.Baseline___Patient had pocket depths on 4 generalize mostly on her molars. She has 4mm
pockets #2 BD, #13 MB and DB, #14 M&D, #18 DB, #31 BD. These pockets many get deeper
once I remove the calculus on the tooth. The calculus on her teeth can attribute to the loss of
attachment and the progression of bone loss. She had no furcation involvement, no suppuration,
and/or tooth mobility.
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2.Firstevaluation____On the patient’s re-eval, I saw her pocket depths improve. The areas where I
noted 4mm pockets had healed to a normal pocket depth. The only area that I saw worsen was the
distal of #31. This tooth had a pocket depth of 5 which I speculated was this way because of the
impaction of #32, which could lead to a deeper pocket that would heal upon the extraction of that
tooth. I placed arestin in that area to help prevent bacteria from causing more extensive damage to
that area. The placing of arestin in that area was important because it help contribute to a decrease
in plaque buildup, which could lead to a decrease in the progression of the disease.
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5. Dental Examination: (caries, attrition, midline position, mal-relation of groups of teeth, occlusion,
abfractions)__Her had slight attrition on teeth #7,8,9,10,11 and on # 23,24,25,an 26 which
contributed to her grinding. She had multiple occlusal caries on teeth #_2,3, 19, 29, and 31, which
could cause loss of tooth structure as well as bone loss. She was missing tooth number 30. She also
has impacted third molars which could contribute to bone loss on the surrounding teeth. This could
also cause a difficulty place to brush, which can contribute to a location where bacterial can
grow. Which could
contribute to decay causing periodontal disease.
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6. Treatment Plan: (Include assessment of patient needs and education plan)

App't 1: _______The first appt was used to do an initial assessment on Her to have an
understanding of the progression of her periodontal disease. I will use this baseline to compare to
her initial to her final treatment. I will discuss with the patient about brushing, flossing, caries,
and how all this can attribute to the progression of disease.
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App't 2: ___
I will use my flip book to help aid the her in obtaining the information presented to her.
I will try to use other aids to help her understand that the halting of her periodontal disease is
what we are trying to accomplish.
Patient education: I will talk to her about her long and short term goals
1.BRUSHING: HABITS
A. Discuss plaque and how it can contribute to the periodontal disease
B. Talk to her about her plaque score 1.5(Fair) and try to work as a team to lower it by .3 by
every appt.(short term)
C. Get a soft bristle toothbrush to avoid damage to her teeth and demonstrate her the amount
of pressure needed. (short term)
D. Try to lower her plaque score to a least below 1(good) by her last appt. (long term)
2.FLOSSING HABITS:
A. Discuss periodontitis and how it can contribute to loss of attachment and bone loss.
B. Discussing her bleeding score and how it an indicator to disease. (short term)
C. Talk to her about her bleeding score 6% and try to work as a team to lower it by 2 by
every appt. (short term)
D. Demonstrate her the correct way to floss
E. Examine if her flossing has improved and her bleeding score has dropped below her
initial visit by her last appt. (long term)
3. Caries
A. Discuss caries and how the combination of bacteria, tooth surface, the duration on the
tooth, and the amount effects the initiation of the caries process.
B. Review the patient about her multiple caries and help her find a dentist nearby that can
help her with it. (short term)
C. Talk to her about sealants and try to at least fill teeth that are vulnerable to caries. ( short
term)
D. Have the patient at least have some of her teeth filled by next recall appt. (long term)
2.Intraoral pictures taken
3.Plaque score and bleeding score checked.
4.Ultrasonic LL quadrant
5.Full perio charting on LL
6.Fine scale LL
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App't 3: _
1. Assess her gingiva on LL quad
1.Patient education: periodontitis
 A. I will talk to my patient about periodontitis and explain her its irreversible and it can
cause loss of tooth structure and eventually the tooth.
B. I will discuss flossing and demonstrate the correct way to do it. I will let her repeat back
to me what we discuss.
C. By next appt. I will briefly discuss flossing again to see if she retain the information.
2.Ultrasonic LRwith anesthetic if needed
3.full perio charting on LR quad
4.Fine scale the remaining LR quad

App't 4: __
1.Assess gingiva on LR
2.Plaque score and bleeing score checked.
3.Patient education: Gingivitis
A. Use flip book to discuss gingivitis. How it’s the its the first sign of periodontal disease
and its reversible. Demonstrate to her inflamed tissue and bleeding can contribute to its
progression.
B. I will explain to her the correct way to brush and then have her teach me.
C. By next appt. I will briefly discuss brushing again to see if she retain the information.
4.Ultrasonic UR quad with anesthetic if needed
5. Full perio charting on UR quad
6.Fine scale the remaining UR quad
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_____App't 5:
1. Assess gingiva on UR quad
2.Plaque score and bleeding score checked.
3.Patient education: Caries
a.Use flip book to discuss caries. How it’s the progression of bacteria with a long contact time
with the tooth. I will describe how it usually looks like a hole on the tooth.
b. I will explain how brushing and flossing can help remove the plaque from the teeth and how a
nutritious diet can help avoid its occurrence.
c. I will demonstrate the usage of fluoride can help remineralize the loss minerals of the tooth
and help prevent it from getting larger.
4._Ultrasonic UL quad with anesthetic if needed
5. Full perio charting on UL quad
6.Fine scale the remaining UL quad
7. Polish all four quadrants
8.Plaque free
9.Fluoride treatment

App't 6:
1. Final evaluation of gingiva with final gingiva index
2. Reprobe full mouth and apply Arestin in pockets.
3. Recheck if any calculus was left over.
4.Discuss goals one more time
5. Set up recall appt. for spring
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7. Radiographic Findings: (crown root ratio, root form, condition of interproximal bony
crests, thickened lamina dura, calculus, and root resorption)
_mild horizontal bone loss to the UR and UL quadrants. The loss of bone could indicate
Periodontists which can cause further damage to the dentition in the future. _I found impacted
third molars(1, 17, and 32, that could lead to the destruction of bone to the adjacent structures or
lead to a pocket that could harbor bacteria.
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8. Journal Notes: (Record in detail the treatment provided, oral hygiene education, patient response,
complications, improvements, diet recommendations, learning level, progress towards short and long
term goals, expectations, etc.) The progress notes should be written by appointment date.
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_____Appt 1: 11/17/17: I started her initial exam. I review her medical and dental history with
her to see if there were any changes that could cause any contradictions to her cleaning. I took
her vitals, which was 126/78 (pre-hype), and her pulse, respiration, and temperature which were
all normal. I follow with a pre-rinse to help with the decrease in bacteria. I began with her head
and neck exam which I found everything normal. I then did an intra oral exam, and found out she
had linea alba because of her biting her cheek. I also found her gingiva was pigmented and that
she had anklyglossia. In her occlusal examination I found a class 1 occlusion except for her right
side, which was missing her first molar, so it could not be classified. I follow up with her perio
assessment, which I found her gingival normal except to her mand anteriors. This area had red,
spongy with rolled margins on both her facial and lingual sides. I found horizontal bone loss
usually located to her maxillary dentition. I gave her a class 2 perio because of her bone loss, and
described her gingival condition as generalize marginal. I followed her perio assessment with her
dental charting, I found a few carious lesions on #3, #4, #19, #29, and #31. I also found that her
third molars were impacted. After dental charting, I probe her pocket depths to see if there were
any areas with 4mm or higher. I also took her gingival index to see if it would improve by her
final appt. My next step was to take her plaque score and bleeding score, and began patient
education. I discuss her long term and short-term goals with her. I discuss a plan to help her
decrease her plaque score and bleeding score by each appointment, and to eventually come to a
good number at the final appointment. I demonstrated on how to use the Bass method to brush,
the time required, and how much pressure to apply. She showed a lot of enthusiasm, so I gave
her learning level of “action”. I finally end the appt by going over the informed consent and risk
assessment with her, and tried to explain everything slowly and pause to see she had any
questions. At the end of the appt I believe she was more that eager to return to finish her
cleaning. She was motivated on her desire to improve her oral health. I ran into no complications
with her.
Appt 2: 11/20/17: I review her medical and dental history again, and found no complications. I
took her vitals again, and gave me a reading of 118/74, with the rest of her vitals normal. I took
intra oral pictures at this time, so I could use in conjunction with her patient education. I pre-
rinse and then took her plaque score and bleeding score again. I saw an improvement in her
numbers and then follow up with some patient education. I went over her long term and short-
term goals again, and gave her a goal to hit at the final appt. I discuss with her periodontitis and
its role in destroying bone and causing extensive damage to her periodontium. I demonstrated
flossing and how to wrap around her tooth in a “c” shape form and to go up and down to remove
bacteria. I also gave her a learning level of “action” again because of her trying to follow this. I
also discuss with her about her diet at this point to see if I could at least educate her on the
importance of a healthy nutrition and how it can correlate to her oral health. After an extensive
discussion, I started on her scaling. I removed all the calculus that I could feel on all her
quadrants. At the end of every quadrant I perio charted, so I could have a baseline on her pocket
depths. I also didn’t run into any complications during this appointment, and she continued to
show motivation to improve her oral health.
Final Appt: 12-1-17:
I review her medical and dental history again and found no changes. I took her vitals and got a
reading of 114/78, and the rest of her vitals were normal. I started by taking her plaque score and
bleeding score and saw an improvement from her previous appt and saw that she had followed
her goals by this time. I compliment her by following the long and short terms goal I had given at
the beginning. I discuss fluoride on this appointment and its role in helping remineralize the
enamel and prevent caries. I discuss with the progression of the caries process and showed her
the areas, with the pictures I took with the intraoral camera on her second visit, where she had
some caries. The next step I did was to explore her mouth to see if there was any calculus left. I
probed her whole mouth and found an improvement on her pocket depths and her gingiva as
well. I followed up by doing plaque free and placing sealants on #2, #15, and #20. I placed
arestin on the distal of #31 to help decreasing the bacteria in that pocket. I finish her appt by
applying topical fluoride on her teeth and describing the instructions to her. I set up a recall appt
for her in three months( 2/18) to see if her healing has improved. In this appt I also did not run
into any complications.
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9. Prognosis: (Based on attitude, age, number of teeth, systemic background, malocclusion, tooth
morphology, periodontal examination, recare availability)

______I believe my patient has a good prognosis based on her final evaluation. Her pocket
depths improved, her plaque score, bleeding score, and gingiva index went down, and her
demeanor on improving her oral health increased. The impaction of her third molars and missing
#3l may lead to a worse prognosis, but her attitude towards taking care of her teeth leads me to
believe it won’t be a problem once she extracts them. The carious lesions on multiple teeth could
as be a factor on her prognosis as well. The inability to get them taken care could lead to
destruction of that tooth and may lead to a worsen of the disease. Although she is in her early
30s and has of a lot on her plate. She continues to demonstrate an improvement of her oral
habits. She does not have any systemic diseases and no abnormalities that could cause any
contradictions.
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10. Supportive Therapy: Suggestions to patient regarding re-evaluation, referral, and recall schedule.
(Note: Include date of recall appointment below.)
_I discuss with patient on her recall in February in 2018 or later based on her having slight
periodontitis and having improved her oral habits. During this exam, I will evaluate the progress
of her gingiva and to examine if she had followed her oral habits. This recall will be my perio
maintenance, I will try to see if her the progression of periodontitis had halted. I explain to her
the importance of coming back so there won’t be an attachment loss during this time. I will also
try to explain to her about one of her long-term goals regarding taking care of some of her
carious lesions. I also discuss getting her third molars extracted because of the possibility of
destruction of bone and adjacent structures. As this could also lead to bacteria to harbor in those
areas that could have deep pockets.
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11. Assessment of Changes: (including plaque control, bleeding tendency, gingival health, probing
depths)
___Her’s final appt her gingiva showed an improvement. Her plaque score and bleeding score
had decrease by each appointment. The decrease of her bleeding score indicated that the
progression of periodontitis had decreased. The pockets depths of her last appointment also
shown an improvement. However, there was one area that showed an increase in pocket depth,
which I believe could indicate another factor. The texture of her gingival was another
improvement that I saw. The anteriors of the mandible had the most inflammation, after the
removing of the calculus the inflammation decreased. These changes had made me aware that
the progression of the disease had halted.
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12. Patient Attitudes and Cooperation:

__Her was a great patient. She was eager to learn and ask me many questions that I was more
than happy to answer. She improved her brushing habits and floss daily, which I could see based
on her plaque and bleeding score. She followed her Long term and Short-term goals. She also
scheduled herself an appointment to a dentist to help fill those areas on her teeth that had caries.
She also mentioned visiting an oral surgeon after her graduation to remove the impacted third
molars. Overall, she was an exceptional patient, she had the desire to improve her oral health and
to continue coming for her cleanings.
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13. Personal Evaluation/Reaction to Experience:

___I learned a great deal upon this experience. I witness drastic improvements on my patients
gingiva by removing the local contributing factor as well in improving her oral habits. I believe I
improved as a dental hygienist in way that I understood the reasons why a factor could be the
difference in improving a patient’s oral health. This experience has shown me that with
teamwork between the patient and dental hygienist, one can make a big difference in someone’s
oral and overall health.
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