DENTAL HYGIENE CARE PLAN TEMPLATE

Care Plan submission will use findings from included patient information.
Student Name: Macy LeBlanc
Patient Name: Mary Moreno Age: 44
Chief Complaint: Stained teeth and bad breath
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: ______________

I. Diagnosed with rheumatoid arthritis I. Can have dental implications due to

II. Patient takes Methotrexate difficulty of brushing or medication
III. Smokes a pack of cigarettes daily side effects. At risk for dry mouth,
IV. Drinks on the weekends fatigue, insufficient plaque removal,
and TMJ joint inflammation and pain
I. Dental implications of methotrexate:
can cause oral ulcerations and has a
potential link to delayed healing and
medication-related osteoriecrosis of
the jaw. At risk for nausea, vomiting,
increased risk of infection, bleeding
and poor health.
II. Risk factor for the progression or
development of periodontal disease.
Smoking is associated with deeper
periodontal pockets, clinical
attachment loss, oral cancer, delayed
healing, stained teeth and mucosa
halitosis.
III. Alcohol combined with smoking puts
the patient at a higher risk for oral
pathology such as cancers and
periodontitis.
IV. Biofilm, plaque, and calculus
accumulation can result in
periodontal disease, undiagnosed
caries and possible oral pathology
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:_____________

I. Chief complaint: stained teeth and I. Stained teeth that result from
bad breath smoking. Progression of periodontal
II. Patient does not floss disease. Possible oral pathology on
III. Eats sugary mints throughout the day the tongue.
IV. Slight nicotine stomatitis II. Developing carious lesions on the
V. Has not had a dental exam or cleaning proximal surfaces and inflamed
in 10 years gingival tissue.
III. Developing dental caries.
IV. Patient has a higher risk of developing
oral pathology.
V. Plaque and calculus build up along
with possible undiagnosed caries,
periodontal infections, and oral
pathology.

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:___________

I. Higher risk of developing oral

I. Slight nicotine stomatitis pathology and cancers.
II. Generalized moderate to heavy II. Higher risk of developing oral
brown stain on gingival tissue pathology, smokers melanosis,
III. Discoloration on tongue leukoplakia and cancers due to
etiology.
III. Possible oral pathology (thrush).

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:_______________

Patient is at risk for progression of

Patient exhibits generalized moderate periodontal disease due to generalized
subgingival calculus and stained biofilm maxillary and mandibular probe depths of 5-
 (class 4), 30% generalized horizontal bone 6mm. In addition, the biofilm retentive
loss, generalized maxillary and mandibular features put this patient at risk for clinical
probe depths of 5-6mm, and biofilm attachment loss, bone loss, and progression
retentive features (crowding on mandibular of periodontal disease and carious lesions.
anterior teeth and broken TCR on #3-MO
and #5-MOD). Patient has generalized
severs papillary enlargement smooth red
papilla with rolled margins, generalized
whitened and fibrotic consistency and
stippled attached gingiva.

a. Gingivitis _____ or Periodontitis Stage: _III___ Periodontitis Grade: __C__

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:_________________

I. Progression of periodontal disease,

I. Generalized 30% horizontal bone loss tooth loss, and tooth mobility.
II. Missing #19 II. Difficulty chewing. At risk for bone
loss, extrusion of opposing teeth, and
malocclusion within the same arch.

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:___________________

I. #30-MO broken TCR restoration I. Developing recurrent caries and

II. #5- MOD broken TCR restoration biofilm retention
III. Missing #1, 16, 17, 19, and 32 II. Developing recurrent caries and
IV. Slight crowding on mandibular biofilm retention
anterior III. #19 missing area is at a higher risk of
periodontal disease. Patient may have
difficulty eating on that side.
IV. Biofilm retention area that can cause
an accumulation of plaque, calculus
and at risk for caries development
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:_________________

I. Habit, lifestyle, addiction

I. Smoking (bad breath and staining) II. Insufficient plaque removal,
II. Plaque and calculus infrequent dental care
III. Periodontists III. Plaque and biofilm, smoking,
IV. Broken restorations/ caries risk infrequent dental care, inadequate
V. Missing #19 plaque removal
IV. Plaque bacteria, xerostomia,
cariogenic diet, infrequent dental
exams
V. Unknown reason for extraction-
question patient

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: Home Care evaluation:
 Medical and Dental History  Brushes daily
 Radiograph  Does not floss
 Intraoral and extraoral exam  Does not use mouth rinse
 Dental charting  Heavy plaque present
 Periodontal assessment
 Plaque and bleeding scores
 Chairside patient education and OH
evaluation
 Risk assessment
 Informed consent

Appointment 2:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
 LTG #1: Lower patient’s plaque  Patient Education
 Review Medical score to 0.1 by the end of session 1: Plaque and
 and Dental treatment. toothbrushing.
History with  After taking patient’s
patient.  STG: Understand plaque and plaque score,
how it forms by the end of educate patient on
 Plaque and session 1. what plaque is, how
Bleeding score often it forms and
 STG: Understand the proper
how it is removed.
 Patient way to brush and floss by
 Review proper
Education the end of session 2.
brushing techniques
session #1
(plaque and  STG: Patient will reduce with patient ed
toothbrushing) their plaque score to “fair” notebook and
or 2 plaque score by patient demonstrating on
 Scale Maxillary education session #2. typodont
Right Quadrant
with  STG: patient will reduce  Disclose patient and
anesthesia. their plaque score to “good” have them brush and
or 0.1 by session #3. modify where
necessary in patient
ed room

 After establishing
patients' compliance
with the long-term
goal, begin scaling UR
quadrant with
anesthesia.

Appointment 3:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
 Review Medical  Patient Education
and Dental  LTG #2: Have patient complete session 2:
History with tobacco cessation by 11-30-24 Periodontitis and
patient. Tobacco Cessation.
 STG: Patient understands how
 Plaque and tobacco affects oral health and  Review last sessions
Bleeding score progresses periodontal disease topics, and have
patient demonstrate
 Patient proper brushing on
 STG: Patient shows willingness
Education typodont. After the
to complete tobacco cessation patient shows
session #2
 (periodontitis  STG: Patient starts competence in
and tobacco implementing nicotine topics, move on to
cessation) alternatives such as nicotine session #2.
patch, nicotine inhaler, nicotine
 Scale gum, or nicotine lozenge by 1-  Educate patient on
Mandibular 20-23 Periodontitis with
Right Quadrant patient ed notebook
with and power point.
 STG: Patient makes
anesthesia. Show patient bone
appointment for tobacco loss on their
cessation therapy/counseling radiographs.
with appropriate healthcare
provider 3-30-24  Educate patient on
the effects of tobacco
on the oral cavity and
possible treatment
options with patient
ed notebook and
power point.

 After session, begin

scaling the
Mandibular Right
quadrant with
anesthesia.

Appointment 4:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
 Review Medical  LTG #3: Have patient  Patient Education
and Dental restore their carious lesions session #3: Caries and
History with by next year. 11-30-24 flossing
patient.
 STG: Patient shows  Review last sessions
 Plaque and understanding of caries, topics, and have
Bleeding score caries development and the patient demonstrate
relation to the diet. proper brushing on
 Patient typodont. Disclose
Education  STG: Patient makes
patient and modify
session #3 appointment to have #3-
where needed.
(Caries and MO and # 5-MOD restored
flossing) with DDS.
 Educate patient on
proper flossing
  Scale Maxillary  STG: Patient makes technique by
Left Quadrant appointment to have #3- demonstrating on the
with MO and # 5-MOD restored typodont.
anesthesia. with DDS. 12-20-23  Allow patient to
demonstrate on
typodont and in the
mirror.

 Educate patient on
caries development
and dietary relations
with patient ed
notebook and power
point.

 Begin scaling
maxillary left
quadrant with
anesthesia

Appointment 5: (if needed)

Plan for Treatment: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
 Review Medical  Review patient
and Dental education sessions
History with #1-3 chairside.
patient.
 Take plaque and
 Plaque and bleeding scores
Bleeding score
 Modify brushing
 Scale
Mandibular technique if needed
Left quadrant chairside
with
anesthesia.  Review all LTG and
STG with patient
 Polish teeth
with prophy  After review, begin
paste and scaling the
apply fluoride Mandibular left
varnish. quadrant with
 anesthesia.

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)

The prognosis for this individual is fair based on the following: Patient is middle age, has
generalized moderate radiographic bone loss, is a chronic smoker, has 28 natural teeth,
insufficient plaque removal, infrequent dental care, and a systemic condition/ medication
with oral side effects and potential for delayed healing.

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

Recall patient in 3 months for periodontal maintenance and re-evaluation. This appointment
will be February 2024 and we will determine if patient is continuing with long-term goals.
Referrals to patient’s general dentist were given for #3-MO and #5-MOD, and consult
regarding missing tooth #19. Referral to appropriate medical professional for smoking
cessation/habit control therapy.