DENTAL HYGIENE CARE PLAN TEMPLATE

Care Plan submission will use findings from included patient information.
Student Name: Daniela Guillen
Patient Name: Jamie Boler Age: 43

Chief Complaint: Bad breath and stained teeth

1. Medical History: (list any positive medical history findings from the medical & social history.
Correlate what the positive findings place the patient at risk for.)
Medical History Findings at Risk For: ______________

1. Smoked since she was 17 years old 1. Oral and Pharyngeal cancers,
and smokes 1 pack a day, combines halitosis, dental stains, tooth loss,
smoking and drinking alcohol during nicotine stomatitis, smokers'
the weekends melanosis, acute necrotizing
2. Recently diagnosed with rheumatoid ulcerative gingivitis, acute necrotizing
arthritis, ulcerative periodontitis, high rate of
3. Takes methotrexate periodontal disease progression,
4. Stage 1 hypertension delayed healing, localized recession
and clinical attachment loss, and
increased pocket depths
2. Patient is predisposed to developing
gingivitis and periodontitis because of
pain, homecare limitations and
compliance, limited dexterity, dry
mouth (xerostomia), stiffness, fatigue,
insufficient plaque removal, TMJ/joint
inflammation, and pain.
3. It has dental side effects of ulcers in
the oral mucosa, nausea, vomiting,
stomatitis, increased risk for infection,
poor healing.
4. Medical emergency

2. Dental History: (List past and/or present dental disease, the chief complaint, and the present
oral hygiene habits. Correlate what the findings place the patient at risk for.)
Dental History Findings At Risk For:_____________
 1. Infrequent Dental visits - No dental 1. Plaque and calculus accumulation,
exam/cleaning in 10 years, FMX taken undiagnosed dental caries and other
10 years ago, conditions, periodontitis, progression of
2. Doesn’t Floss perio disease
3. Discolored tongue that has a coating 2. Dental caries, gingivitis, plaque build-up,
4. Eats sugary mints throughout the day, periodontitis, progression of perio disease
5. Heavy brown stains on teeth 3. Bad breath or halitosis and the overgrowth
6. Gums bleed when brushing of bacteria.
4. Dental caries and tooth decay
5. Dental biofilm retention feature and heavy
deposits may penetrate enamel and become
exogenous intrinsic stains.
6. Gingivitis, periodontitis, progression of
perio disease, and possible poor compliance
with future homecare instructions.

3. Extraoral & Intraoral Examinations: (List the positive findings, occlusion, midline shifts,
habits and awareness. Correlate what the findings place the patient at risk for.)

Extra & Intraoral Examination Findings At Risk For:___________

1. Found generalized slight nicotine 1. Premalignant and malignant mucosal

stomatitis on hard palate, lesions, oral cancer
2. Generalized moderate to heavy 2. Smoker's melanosis, oral lesions,
brown stains on buccal mucosa, leukoplakia

4. Periodontal Examination: (Describe the gingival color, contour, texture, and consistency. List
general biofilm locations, biofilm retentive features, predisposing factors to biofilm retention,
pocket depths, CAL, bone loss, make reference to location of bleeding sites, etc. Determine
periodontal diagnosis. Correlate what the findings place the patient at risk for.)
Periodontal Assessment Findings At Risk For:_______________

1. Has generalized severe gingival 1.Periodontitis, Gingivitis, Plaque retentive

enlargement, fibrotic, whitened features
margin, papillary redness with rolled 2. periodontitis
margins, stippled attached gingiva 3. gingivitis and periodontitis
2. Generalized maxillary and 4. gingivitis and periodontitis
mandibular probing depths of 5-6
mm
3. Localized bleeding
4. Class 4 calculus
 a. Gingivitis _____ or Periodontitis Stage: 2 (or 3- unknown CAL) Periodontitis Grade:
C (smoking)
b. Plaque Score: 3.5 Evaluation of plaque score: poor
c. Bleeding Score: 16%

5. Radiographic Findings: (List the conditions such as crown to root ratio, bone loss, condition
of interproximal bony crests, thickened lamina dura, calculus, decay, root resorption, etc.
Correlate what the findings place the patient at risk for.)
Radiographic Findings:___________________________At Risk For:_________________

1. Generalized 30% bone loss 1.tooth loss, periodontitis, progression of

2. Generalized moderate subgingival perio disease, attachment loss
calculus 2. dental caries, tooth decay, receding gums,
3. Moderate stained biofilm gingivitis, periodontitis, progression of perio
4. Missing #1, #16, #17, #19, #32 disease
3. Plaque build-up, aesthetic issues,
gingivitis, perio disease progression

6. Dental Charting Examination: (List all findings from dental charting exam. Examples are
caries, attrition, abfractions, etc. Correlate what the findings place the patient at risk for.)
Dental Charting Findings: At Risk For:___________________

1. Broken TCR #3 MO and #5 MOD 1. infection, tooth sensitivity, recurrent

2. Missing #1, #16, #17, #19, #32 caries, plaque retention, tooth decay
3. Mandibular crowding 2. shifting of teeth, food impaction, biofilm
retentive features
3. biofilm and plaque retentive features,
difficulty brushing and flossing, food
impaction, gingivitis, perio disease
progression

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:_________________

1. Smoking (bad breath and staining) 1.Habit, lifestyle, addiction

 2. Plaque & calculus 2. insufficient plaque removal and infrequent
3. Periodontitis dental care
4. Broken restorations/caries risk 3.plaque biofilm, smoking, infrequent dental
5. Missing #19 exam, inadequate plaque removal
Plaque bacteria, xerostomia, cariogenic diet,
infrequent dental exam
5.unknown reason for the extraction- need to
question patient about it

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 3 short-term goals.

Appointment 1: (Initial Appointment- patient assessment & data collection)

Completed: Completed Home Care evaluation:

Completed patient’s Uses Power Toothbrush

Medical Dental History, Brushes Daily
Took Vitals, Unknown brushing Technique
Intra and Extra Oral Exam, She does not floss
Periodontal Exam, She smokes
Plaque and bleeding scores, Eats a cariogenic diet
Took radiographs and identified
Radiographic Findings,
Dental Charting,

Pt. Ed #1: plaque and toothbrushing

Pt. Ed #2: Gingivitis, Periodontitis, Flossing
Pt. Ed #3: Smoking
Pt. Ed #4: Frequent Dental Visits

Appointment 2:
Plan for Treatment: Goals: Reduce Plaque score Plan for
Education and/or Oral
______________________________________________________Hygiene Instruction________
Review her medical  LTG #1: Patient will decrease We start the patient
and dental history. plaque score by zero once education session by going
Plaque and bleeding treatment has been completed over our appointment 1 and
scores. seeing if the patient has
Patient education  STG: Patient will decrease made any changes to her
session one will be her plaque score by 1 point home care. I will give
about Plaque and by every appointment. positive feedback and
ways to remove it answer any questions or
properly.  STG: Patient will properly confusion she may have. We
Scale UR with demonstrate toothbrushing will also be learning about
anesthesia technique, use of plaque, thus starting our
interdental aid, and tongue first patient education
scraper by end of this session. I will ask Jamie what
session. she knows about it and how
she removes it with
 STG: patient will eliminate brushing. I will talk to her
bad breath and tongue
about how it forms and
coating by next
ways it can build up in hard-
appointment.
to-reach places. Informing
her that plaque can cause
halitosis, dental caries,
gingivitis, and periodontitis.
I will suggest learning a new
brushing technique that will
help remove most plaque
and be easy for her because
of her arthritis. We will ask
her to practice the new
brushing technique and give
pointers and positive
feedback. We will also go
over the importance of
flossing daily and how it can
help remove plaque in
places tooth brushing alone
cannot reach. I will show her
different interdental aids to
help with her rheumatoid
arthritis and demonstrate
the use of them and then
ask her to repeat on the
typodont. Give her positive
feedback. I will then bring up
using tongue cleaners to
 help remove the coating on
her tongue to help her get
rid of bad breath. I will
demonstrate then ask her to
repeat. Once I see she has
the proper techniques down
I will recommend her to do
these at home. After
suggesting the new home
care routine, we will put her
on a 3 month recall schedule
to see the progression of her
oral health.

Appointment 3:
Plan for Treatment: Goals: Control periodontitis Plan for
Education and/or Oral
______________________________________________________Hygiene Instruction________
Review Medical and  LTG #2: Patient will decrease The first thing we do for our
Dental History for new progression of periodontal 3rd appointment is to go
updates. disease by improving bleeding back and look at her
Retake plaque and score 80% end of treatment. progression from the
bleeding scores to previous appointments to
check for  STG: patient will reduce check if she accomplished
improvement or
bleeding score by 20% each any of her short-term goals.
worsening.
appointment I will give back positive
Patient Education
Session over feedback. We will compare
Periodontitis.  STG: patient will understand this appointment's scores
Scale UL with what periodontitis is, any with previous scores to see if
anesthesia. risk factors that can cause it, she is doing her home care
and make it progress by end properly. Our 3rd patient
of session. education session will cover
periodontitis. I will ask her
 STG: patient will correlate what she knows about it and
bleeding and the active if she can point out any risk
infection of periodontitis by factors. We will go over how
end of session. our diet, visits to the dental
office, smoking, flossing, and
her rheumatoid arthritis can
contribute to periodontitis
and the progression of it. I
 will show her the
radiographs, her bleeding
score, probing depths, the
bone loss, attachment loss,
and explain her periodontal
stage and grade. We will
come up with a plan to help
slow it down together. I will
inform her that we are going
to be a team. I will then ask
her to recount what she
learned and ask how she will
do her home care. Positive
feedback will be given and
suggestions. I will then
inform her about our next
upcoming patient education
sessions- tobacco cessation.

Appointment 4:
Plan for Treatment: Goals: Quit smoking Plan for Education
and/or Oral
______________________________________________________Hygiene Instruction________
Review  LTG #3: Patient will quit We will start this
medical/dental history smoking by end of treatment. appointment by asking
Check plaque and about previous goals and if
bleeding scores  STG: Patient will understand she has been able to follow
Patient education how smoking affects oral and accomplish them. We
session 3 over tobacco health and hygiene by end will compare this
cessation of session appointment's plaque and
Scale LR quadrant with bleeding scores with
anesthesia  STG: Patient can use previous scores to see if
nicotine patches, nicotine there have been changes.
gum, or non-nicotine Give back positive feedback
pharmatherapy, or other and tell her excellent job if
alternatives to smoking by she has been following her
end of session home care plan. Then move
on with patient education
 STG: Patient will be able to over tobacco cessation. Ask
link smoking with bad her about her history with
breath, teeth staining, smoking, and if she knows
progression of periodontitis, the risks smoking has on oral
and development of health and hygiene. I will
rheumatoid arthritis by end inform her of the risks
of session. smoking has including oral
and other types of cancer,
inform her about how
smoking and drinking
alcohol puts you at a greater
risk for periodontitis, teeth
staining, bad breath, and
tooth decay. I will also
inform her about the link
smoking has to the
development of rheumatoid
arthritis. We will tell her
about the correlation of her
teeth staining, halitosis,
nicotine stomatitis, brown
stains on buccal mucosa, and
periodontitis is results from
her smoking. I’d let her
know that once we remove
the stains on her teeth if she
continues to smoke, she will
see treatment failure. If she
agrees and wants to see a
decrease of all that was
listed, we will help find her
the best treatment plan to
help her quit smoking and
create it. Counseling,
medication, positive
reinforcement, therapies,
support groups, and online
resources will be provided
for her. I will let her know
that it will be a team effort
and that we may refer her to
a periodontist if we do not
see improvement or
 compliance with her home
care. Then we will ask her to
review what we went over
and show us she has
understood. Let her know
that next appointment we
will go over the next topic.

Appointment 5: (if needed)

Plan for Treatment: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
Review Medical and LTG: More frequent Dental Visits We start this appointment
Dental history by end of treatment by reviewing compliance
Plaque and bleeding with our home care plan and
scores STG: patient understands checking if we have good
Scale LL quadrant with how important it is to changes. I will give positive
anesthesia regularly visit your dentist feedback and reinforcement
by end of session if our goals are accomplished
or close to being to.
STG: patient understands We will see an improved
and can explain the risks of plaque score, bleeding score,
not frequently visiting your and halt in periodontitis
dentist like increased dental disease if she sticks to her
caries risk, progression of home care plan. She will
periodontitis, and possible have to keep up flossing
undiagnosed conditions by daily, healthier diet, more
end of session visits to the dentist, and
quitting smoking. I will
explain to her that we
shouldn’t have to be
experiencing pain to go see
the dentist and that many
diseases can be reversible
and better treated if they
are caught early on. We end
this appointment by letting
her know about the 3
months recall schedule and
 that we hope to see her
soon.

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)

Her prognosis is fair because Jamie Boler is 43 years old. She has generalized moderate
radiographic bone loss, is a chronic smoker smoking 1 pack of cigarettes daily. She has 28
natural teeth, but her plaque removal is insufficient, and she has not been to the Dentist in
10 years. She only goes to see doctors if she is experiencing any sort of pain. It was put down
that her time is very limited because she has a stressful job. She was diagnosed with
rheumatoid arthritis which is a systemic condition and takes the medication methotrexate
which has oral side effects and the potential to delay healing.

10. Supportive Therapy: State the suggestions made to patient regarding re-evaluation,
referral, and recall schedule. (Note: Include date of recall appointment below.)

1. Recall every 3 months due to high risk of progression of periodontitis.

2. Referrals to patient’s dentist for broken TCR’s 3-MO and 5-MOD and consult
regarding tooth #19 because it is missing.
3. Referral to medical professional for smoking cessation and habit control therapy.
I suggested new toothbrushing techniques, flossing daily with help from an interdental aid,
use of mouthwash and toothpaste with fluoride, change of diet, switch to mints with xylitol,
and quitting smoking.
These suggestions were made to see a reduction in bad breath and teeth staining.
Also, to halt the progression of periodontitis, further bone loss, and see better probing
depths. To also lower her plaque and bleeding score.