CARE PLAN TEMPLATE

Care Plan submission will use findings from included patient information.
Student Name Chloe Benoit
Patient Name ------- Age 25
Chief Complaint:” My gums bleed all the time”

1. Medical History: (list any positive medical history findings from the medical & social
history. Correlate the finding places the patient at risk for.)
Medical History Findings At Risk For:
Patient is 14 weeks pregnant Drowsiness, weakness, loss of
Patient is taking prenatal vitamins and cyclizine Coordination, nausea, dry mouth
Patient is under the care of her OB-GYN constipation and blurred vision
due
To her medication. Periodontitis,
gingivitis, enamel
erosion,
possible
Poor hygiene due to fatigue
2. Dental History: (List past and/or present dental disease, the chief complaint, and the
present oral hygiene habits. Correlate the effects on periodontal diagnosis, and/or care)
Dental History Findings At Risk For:
Patient states that her “gums bleed all the time” Caries, Gingivitis, and
Periodontitis, Many cavities decreased morale for homecare,
Suspicious areas in the mouth TMJ problems, attrition,
recurrent Xerostomia caries, sensitivity
Class 2 calculus supra and subgingival

3. Oral Examination: (List the positive findings, habits and awareness. Correlate the effects
on periodontal diagnosis)
Oral Examination Findings At Risk For:
Lower labial mucosa magenta and reddened Gingivitis, possible infection
Tonsils removed Periodontitis
Reddened area bilateral anterior tonsillar pillar peritonsillar abscess
Enlarged thyroid hormonal imbalance/
hypothyroidism
4. Periodontal Examination: (make a statement regarding the color, contour, texture,
consistency, general biofilm locations, biofilm retentive features, predisposing factors to
biofilm retention, overall pocket depths, bone loss, make reference to location of bleeding
sites, etc.)
Patient has generalized moderate marginal and papillary redness with edematous papilla,
localized severe edematous papilla between #29 and 30. Generalized interproximal 4mm pocket
depths with localized 5mm between # 29 and 30. No recession present, no furcation’s or
mobility. Bleeding everywhere except anterior maxillary teeth. More bleeding on anterior
mandibular due to lingual retainer. Bleeding score 75% and plaque score 55%. Light
supragingival and subgingival calculus deposits.

a. Periodontitis Stage: _I Periodontitis Grade: _A

b. Plaque Score: 2.2%_or 55%_ Evaluation of plaque score: Fair
c. Bleeding Score: 75% Evaluation of bleeding score:_Poor,_generalized >30%_
5. Dental Charting Examination: (List all findings from dental charting exam. Examples are
caries, attrition, midline position, occlusion, abfractions, etc. Correlate to effect on
periodontal diagnosis, progression, and/or care)
Dental Charting Findings: At Risk For:
Class I malocclusion left and right caries
Composite restoration on #3, 14, 19,30 recurrent decay
Missing tooth # 1,5,12,16,17,21,28 and 32
Suspicious areas- 4 MOD, 5 DO, 29 DO, 30 MOD

6. Radiographic Findings: (List the conditions such as crown to root ratio, bone loss, condition
of interproximal bony crests, thickened lamina dura, calculus, and root resorption)
Radiographic Findings: At Risk For:
No loss of crestal bone Caries
Suspicious areas- 4 MOD, 5 DO, 29 DO, 30 MOD Recurrent decay
sensitivity
7. Dental Hygiene Diagnosis: (List all of the dental hygiene related problems associated
with this patient, with each problem list the etiology)
Dental Hygiene Problem: Etiology:
Gingivitis Improper brushing technique/
hormonal imbalance due to
pregnancy Sugar intake, xerostomia
Nausea pregnancy
Xerostomia medication
Recurrent decay demineralization due to vomiting/ diet
8. Treatment/Appointment Plan: (Include assessment findings of patient needs,
appropriate treatment, and education plan- include long and short term goals) Each long
term goal should be supported by at least 2 short term goals.
Appointment 1:
Plan for Treatment: Goals: Plan for Education and/or Oral
Medical dental history, LTG: get patient to change For the first patient
address bleeding gums, take her brushing and flossing education session we will
intraoral pictures of bleeding technique and frequency to focus on the topics of
gums, take x-rays, take arrest her gingivitis by her brushing flossing, gingivitis,
plaque and bleeding score, final reevaluation and plaque. We will make
patient education and appointment sure the patient is aware that
instruction session, cleaning STG 1: patient will pregnancy can induce
and fluoride, deep cleaning, understand that certain gingivitis and periodontitis
root planning/ scaling on brushing techniques are more due to hormonal imbalance.
right maxillary and right effective and how this will She will know that this can
mandibular quadrants improve her bleeding gums. induce early labor and that it
This will be done by the end is important that we get this
of the appointment. taken care of.
STG 2: patient will We will educate the patient
understand the importance on proper brushing
of flossing daily and use of techniques and flossing
the correct technique. This techniques and the
will be done by the end of importance of flossing daily.
the appointment We will report the patient’s
STG 3: Patient will decrease plaque and bleeding score
bleeding score by 15% and set short- and long-term
every recall appointment goals that will address her
every 1 month chief complaint. Take
intraoral pictures to
compare future progress
and take x- rays to assess
bone loss.
Probe the mouth and show
patient the chart to show
patient her bleeding points
and pocket depth. Return
to dental chair for
treatment.

Hygiene Instruction
Appointment 2:
Plan for Treatment: Goals: Plan for Education and/or
Oral Hygiene
Update medical dental Session 2 LTG: reduce Begin patient ed session 2 by
Instruction
history, take intraoral caries by getting all reviewing the previous
pictures of bleeding gums, restorations done by one session and reviewing
take plaque and bleeding year. previous skills. Report to
score, patient education and STG 1: have one cavity patient what their plaque and
instruction session #2, scale filled every month bleeding score for that day
and root plane left STG 2: lower sugar intake by are. Review goals from
Session 1 and determine if
mandibular and left maxillary eating less sugary foods at
patient achieved those short-
quadrants. parties to help reduce
term goals Provide positive
overall caries. feedback. If patient did not
reach the goals, why? Provide
additional instructions to
assist patient in achieving.
Proceed into Patient Ed
session 2 by explaining
caries, fluoride, mouth rinse
and plaque. Review what the
STGs will be and how they
will help the patient achieve
the desired outcome. Use
patient’s intraoral pictures as
visual aides to show
inflammation & recession
inside the mouth. Then use
patient’s probe chart as a
visual aide to show pocket
depths & bleeding points.
Discuss what the patient’s
own bleeding score means
related to the amount of
inflammation. Use patient’s
x- rays as a visual aide to
show bone loss. Reinforce the
importance of thorough
plaque removal daily.
Introduce and demonstrate
the floss threaders as an aide
for interproximal plaque
removal. First demonstrate
the use of the floss threaders
on a typodont. Explain to the
patient that this may be easier
 for her to use than regular
floss on her retainer. Allow
patient to answer open-ended
questions to assess her
understanding of gingivitis
and inflammation. Ask
patient to demonstrate the
floss threader on the typodont
and assess her understanding
of the skill. Invite patient to
the sink, disclose the patient
and ask her to look in the
mirror and identify areas in
her mouth where there is
interproximal plaque
remaining. Ask the patient to
remove those areas of plaque
using the floss, using the
floss threaders. Observe &
assess her ability to use the
floss threader in her own
mouth.
Redisclose the patient and ask
her to look in the mirror and
see if she was able to remove
the areas of interproximal
plaque. Compliment the
patient and provide positive
reinforcement. Return to the
patient ed table and review
the session, asking open
ended questions. Determine if
patient reached the pre-
determined short-term goals
and provide feedback.
Recommend 1- month recall,
emphasize frequent recall for
gingivitis

Appointment 3:
Plan for Treatment: Goals: Plan for Education and/or
Oral Hygiene
Instruction
Update medical dental LTG: continue proper home Begin patient education
history, take intra oral care indefinitely now that session 3 by reviewing
pictures, take plaque and our problems have been previous sessions and
bleeding score, ensure addressed reviewing skills learned.
comfort of patient, patient STG 1: continue to come to Report plaque and
education session 3, check regularly scheduled recall bleeding score that was
restoration development, appointments every 6 taken and compare to past
cleaning, ask patient about months STG 2: educate scores.
baby patient on use of floss Encourage the patient that
threaders to make it easier they are doing good if the
to reach the areas where score is decreasing. Review
patient has a retainer goals from session 2 and
determine if they have
reached these goals. Provide
positive feedback. Proceed
into patient ed session 3 by
explaining interdental
implementation and how
this would benefit her and
also discuss child dental
care.
Show the patient her probing
chart, radiographs, bleeding
and plaque score to show her
how far along she has come.
Introduce the floss threaders
and show on a typodont,
then have the patient
demonstrate the abilities
they have learned. Allow
patient to answer open
ended questions to assess er
understanding.
Disclose patient and ask her
to remove plaque areas with
the floss threader.
Redisclose and ask patient to
see if she was able to
remove all of the plaque.
Compliment the patient and
provide positive
reinforcement. Return to the
 patient ed table review the
session asking open ended
questions. Determine if
patient reached the pre-
determined short-term
goals. Recommend 6 month
recall and return to dental
chair for
treatment

9. Prognosis: (Is the prognosis good, fair, poor, questionable, or hopeless……base

and support your answer on age, number of teeth, systemic/social background,
malocclusion, periodontal examination, recall availability)
Prognosis is good. Patient Is only 25, has had restorations and braces, has had third molars
and first premolars removes, gets teeth cleaned at every recall appointment, is concerned for
her dental health and the dental health of her child, and only a slight class I malocclusion.

10. Supportive Therapy: State the suggestions made to patient regarding re-evaluation,
referral, and recall schedule. (Note: Include date of recall appointment below.)
Suggestions made to the patient are to come back every month until the gingivitis is under
control, the first appointment was 11-23-2020 so the next would be 12-23-2020 and the third
would be 1-23-2021. No referrals are made and as long as patient is meeting goals she should be
restored back to health by end of appointments.