Care Plan
Student Name: Carly Meriwether
Patient: Name Removed
Date of data completion: March 6, 2014
Date submitting plan: March 20, 2014
Synopsis of Patient History
Age:
Sex:
Race:
Weight:
Prophy Class:
Periodontal Type:
26
Male
White
260
3
II
Blood Pressure:
Pulse Rate:
Respiration Rate:
Plaque Score:
Bleeding Score:
1st Appointment
135/90 pre. Hyp. rt
74, +2, norm, reg, wnl
18, reg.,easy,norm,wnl
2.17 fair
10.7 %
Amount and general location of plaque:
Contributing factors for plaque retention:
2nd Appointment
3rd Appointment
Moderate generalized biofilm
Calculus, nutrition, tobacco use, prostheses,
malpositioned teeth
Current Oral Self Care Methods
Toothbrush/brushing
method
Toothpaste
Floss
Power Assisted Appliances
Rinses
Fluoride
Other
Type
Oral B- medium, Horizontal
Frequency
2 X day A.M. & P.M.
Sense dine
n/a
n/a
Listerine
In tooth paste / tap water
2 X day A.M. & P.M.
Doesn’t
n/a
Occasionally 2x daily
daily
Medical/Dental History Summary:
1. Identify any medical problems that the patient might have. Removed doesn’t have any medical
problems
2.
Identify any medical problems that might complicate dental treatment, and what steps should be taken to
minimize or avoid their occurrence.
3.
List any allergies that the patient has reported. Removed has no known allergies.
4.
List medications currently taken by the patient and the dental implications of each. Removed doesn’t
take any medications
5.
Does the patient smoke or use tobacco products? Yes Removed smokes.
Document frequency and type of tobacco products used. Removed smokes 10 cigarettes a day.
6.
When was the patient’s last dental visit? Removed last dental visit was April 2011
What treatment was rendered at this appointment? Removed had a regular dental exam and cleaning.
7.
What is the chief complaint of the patient? Removed reason for coming in is he is due for a cleaning.
(Listed on M/D History)
8.
List any other medical information that you feel is pertinent to the treatment of this patient. There isn’t
any other medical information that is pertinent to Removed’s treatment plan.
9.
List any other dental information that you feel is pertinent to the treatment of this patient. Removed has
calculus on # 5 M, #8M, # 24M, # 25 M&D; Removed also has mild horizontal bone loss on #3, #24,
#25 that will continue to get worse if the patient is not informed about the importance of periodontal
disease and halting the progression. Removed also has root resorption on # 8, & # 9 due to trauma as a
child. Recession on # 12, & # 13.
10.
Assess the patient’s current level of learning and state rationale.
Must be record in progress notes at every appointment. Removed current learning level is aware, he
appears to be more than willing to get involved and with the right oral hygiene information he will be on
his way to having healthier gingiva in no time.
11.
List all positive findings from your data collection on the Chart of Positive Findings.
12.
Use the positive findings to fill out the Chart of Patient Needs.
13.
For every problem listed on the Chart of Patient Needs, state the long term goals for dental hygiene
treatment that have been established by the clinician and the patient. Under each long term goal, state at
least 2 short term goals that will help the patient attain the long term goals.
Plaque – Removed will get his home hygiene care under control by brushing and flossing correctly daily and
reducing his plaque score by .2 each appointment until he reaches a plaque score of 1.7 which is a good
plaque score.
Short term goals:
1. Removed will describe plaque and how it forms by 2nd appointment.
2. Removed will correctly use the Bass method of brushing by 3rd appointment.
3. Removed will choose to floss 2X a week by 4th appointment.
Slight periodontitis case 2 - Removed will choose to halt the progression of periodontitis by getting his home
hygiene care under control by brushing correctly and beginning to floss. He will also use a mouth rinse
daily to help reduce plaque buildup in between his teeth.
Short term goals:
1. Removed will describe and understand periodontitis by 2nd appointment
2. Removed will choose to floss 3X a week by 3rd appointment
3. Removed will choose to use mouth wash daily to reduced plaque between teeth by 4th appointment.
Effects of smoking – Removed will quit smoking by the end of the year.
Short term goals:
1. Removed will take smoking info I have provided for him and use it by 2nd appointment (ex: 1800
quit numbers, where to get help)
2. Removed will replace 3 cigarettes a week with a piece of gum such as trident, which contains xylitol
by 3rd appointment.
3. Removed will cut down even more by now replacing 1 cigarette a day or 5-7 a week with a piece of
gum that contains xylitol by 4th appointment.
14.
State the clinician’s assessment of the possibility of the patient’s goal attainment.
(Ex. excellent, good, fair, guarded, poor). I believe the patient’s goal attainment is good.
Explain your answer. I believe this because although he doesn’t have insurance he has
sufficient funds to pay for a dental visit so he should be able to keep up his visits, he has stated his
interest in quitting smoking if not just for his health but for his daughter also and in learning the proper
way to brush and floss, he has been overly interested in all of the paperwork I have had to fill out about
him and has expressed his interest in what he can do to make his oral cavity healthier. Just in speaking
with him this weekend he was repeating back to me some of the information I have given him as well as
sharing it with others. I believe things can only get better from here on out.
(Consider life-styles, financial ability, social/cultural background, etc.)
15.
Outline the information to be presented in the three Patient Education Sessions.
Include the specific information that will be taught, the methods of presentation, and what visual aids
will be used. Submit on a separate page.
Session 1 Plaque/Brushing
 Flip chart, define plaque: white, colorless, chalky, forms daily, initial problem for hygiene
problems, plaque is bacteria.
 Flip chart brushing most important plaque control method should be a daily routine, what
brushing does for you, how to brush, and give different examples of brushing.
 How to successfully remove plaque- brush 2x a day- using soft bristle tooth brush and fluoride
toothpaste, clean between teeth daily preferably before bed with floss or interdental cleaner to
remove plaque from places tooth brushes can’t reach, eat a balanced diet and limit between meal
snacks, visit your dentist at least once a year for professional cleaning and oral exams.
 Talk about plaque score 2.3 and what she can do to improve her score
 Proper brushing time and technique, bass method use typodont for example 2 minutes 2-3 times
a day, once patient understand the proper brushing technique have him demonstrate on himself
and then we will disclose and take a plaque score to demonstrate effectiveness.
 Express the importance in using mouth rinses with fluoride
Session 2 Slight periodontitis/flossing
 Flip chart periodontitis- inflammation and infection of the ligaments and bones that support teeth
 Use flip chart to go over signs of periodontal disease- swollen gums, tender gums when touched,
bad breath, loose teeth, bright red or purple gums, bad taste in mouth, a change in the way your
teeth fit together, gums that pill away from teeth making them look longer.
 Use x-rays to show patient where he has bone loss.
 Since you can see some of his calculus on his x-rays I can use then to show him where it is and
this should encourage him to floss.
 Use flip chart to review treating periodontitis- get regular professional dental cleanings, use soft
toothbrush and replace every 3-4 months, consider using an electric toothbrush which may be
more effective in removing plaque and tartar, brush teeth after every meal, floss daily, use mouth
rinse to help reduce plaque in between teeth, supplement brushing and flossing with and
interdental cleaner, don’t rely on tartar control toothpaste to do the job that brushing and flossing
should do.
 Use typodont to show patient how to floss properly and that it removes plaque and food particles
in places tooth brushes can’t easily reach - under the gum line between the teeth- plaque buildup
can lead to tooth decay and gum disease
 Give patient tips on how to floss properly. After he can show me properly on the typodont I will
have him show me in his mouth and we will disclose and take a plaque score to show him his
effectiveness.
Session 3 effects of smoking
 Flip chart- explain the effects of smoking such as bad breath, inflammation of the salivary gland
opening of the roof of the mouth, increased buildup of plaque and tartar on teeth, increased loss
of bone within the jaw, increased risk of developing gum disease, a leading cause of tooth loss,
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delayed healing process following tooth extraction, periodontal treatment, or oral surgery, lower
success rate of dental implant procedures, increased risk of developing oral cancer.
Smoking cessation
Describe gum disease- flip chart
Oral cancer- flip chart
Go over proper brushing to keep build up due to smoking under control.
Explain the importance of xylitol in the gum he chooses.
Go over proper flossing to keep build up due to smoking under control.
Provide quitting information including 1800 quit numbers and support groups.
16. Referrals: only referral is to get regular dental visits, don’t wait so long in between cleanings.
17. Recall Schedule: due to Removed having slight periodontitis he needs to be scheduled every 3 months.
11. Chart of Positive Findings
Med/Dent History
Removed states she is in good health; her last physical was in 2011. Last dental exam was in
2011.
Removed is not taking any medications. Removed smokes 10 cigarettes a day.
Intra/Extra Oral Exam
Removed is pyknic, his profile is mesognathic, he has scattered pustules on his forehead
etiology is
bacteria, bilateral razor burn on his cheeks, he also has a scar on the outer canthus of his right
eye he has a lymphadnopothy, left side, pea sized, soft, mobile, 2mm, not tender, etiology soar
throat. Removed clenches his teeth when he is stressed or mad, he tongue thrusts, Removed is
missing
Both his 1st molars on the maxillary so his molar occlusal is unclassifiable, his canines are class
III, no overbite, 2mm over jet, open bite in his anterior teeth, Removed also has a cross bite on
his
Left 2 molars and his left laterals.
Gingival/Periodontal Assessment
Removed has moderate generalized biofilm, biofilm retentive features are calculus, prostheses,
and
malpositioned teeth. Predisposing factors are nutrition, and tobacco. Soft tissue examarchitecture is scalloped, color -red generalized, consistency- edematous/spongy generalized,
Surface texture- smooth & shiny, and stippled in the facial molars, shape, papillae- bulbous
Generalized, shape margins- rolled no suppuration, bleeding is generalized.
Dental Charting
# 1 hypo calcification, #2 hypo calcification - mesioverted , #3 missing, #5 hypo calcification, #8
FTCR,#9 FTCR, #14 missing, #15 OTCR – mesioverted, #16 hypo calcification, #17 missing,
#19 2 metallic restorations O- Facical, #31 Facial metallic restoration, #32 missing.
Generalized bleeding, generalized marginal gingival inflammation. Recession on #12 & #13
Radiographs
Mild horizontal bone loss upper right #3, lower left # 24, & #25
Calculus upper right- #5 M, upper anterior- #8M, lower left- #24M, & # 25 MD, root resorption
#8&#9
Other Findings
Plaque score 2.17 fair, bleeding score 10.7%
12. Chart of Patient Needs
Problem
Etiology
Priority- 1
Bacteria
Plaque
Priority- 2
slight
Periodontitis
Case 2
Bacteria
Priority- 3
Smoking
Stress /
habit
Positive findings
that correlate with
the problem
Plaque score 2.17
Generalized moderate
plaque
Red, edematous,
Smooth, shiny
gingiva
Calculus
Malpositioned teeth
Contributing or
predisposing factors
Patient Education Topics
Treatment Options and
Preventive Therapies
Calculus
Plaque retention
Doesn’t floss
Not brushing
effectively
Tobacco use
Malpositioned teeth
prosthesis
Define plaque
Mouth rinse
Floss properly
Proper brushing
Patient education
Scale
Plaque free
Floss
Mouth rinse
Radiographs
Doesn’t floss
Plaque score
Bleeding score 10.7%
calculus
Not flossing
Not removing all
plaque when brushing
Mild horizontal bone
loss UR, LA
Define periodontitis
Proper brushing and flossing
Importance of flossing
Patient education
Mouth rinse
Floss
Scale
Plaque free
Refer to DDS
Plaque score 2.17
Bad breath
Stain
Inflammation of
gums
Stress
Explain effects of smoking on
mouth
Smoking cessation
Gum disease
Oral cancer
Strategies to prevent stress
Patient education
1800 quit line
Stain removal
Scaling
Plaque free
Mouth rinse