Care Plan Template 1 2
Care Plan Template 1 2
Care Plan Template 1 2
Care Plan submission will use findings from included patient information.
Student Name _Kaeli Bordelon
Patient Name__Kevin Johns Age_20_
Chief Complaint: “My gums bleed when I brush, and it hurts to floss.”
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: ______________
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.lymphadenopathy, infections.
2. pain, jaw damage, loss of bone and
1. Bilateral, pea-sized palpable cartilage.
submandibular lymph nodes. 3. epithelial atrophy, inflammation, reduced
2. Popping and clicking on the left TMJ. keratinization
3. Lower labial mucosa magenta and 4. infection, interference with breathing,
reddened. sinus drainage, swallowing, and speaking.
4. Tonsils are enlarged. 5. oropharyngeal cancer
6. gum disease, affect chewing and speaking,
5. Reddened area bilateral anterior
decaying teeth
tonsillar pillars.
6. Occlusion: class 1 right/left side;
canine and molar.
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. Suspicious areas: 4-MOD, 5-DO, 29- 1.cavities, decay, tooth loss, pain
DO, 30-MOD
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. Mandibular lingual bar from #22-#27 1.caries, gingivitis, perio disease, plaque
2. Sealants on teeth #3, #14, #19 retention, calculus, inflammation
3. Missing teeth #1, #16, #17, #32 2. none
4. Suspicious areas: 4-MOD, 5-DO, 29- 3. teeth displacement and movement, food
DO, 30-MOD stuck in gums.
4. cavities, decay, tooth loss, pain, plaque
retention
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. Plaque & calculus 1. Insufficient plaque removal, infrequent
2. Gingivitis, inflammation, bleeding dental cleanings
3. Caries 2. Plaque biofilm, moderate calculus, poor
4. TMJ popping, clicking homecare, medication
5. Enlarged tonsils/ swollen lymph nodes 3. Plaque bacteria, diet, infrequent plaque
removal, xerostomia, high risk
4. Unknown, possible relation to car accident
or clenching and grinding
5. Unknown, possible illness, infection,
mouth breathing, etc.
Appointment 2:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction_______
- Review Med/Dental LTG #1: show patient how to
history correctly brush and will brush -Ask them if they know
Plaque and Bleeding twice a day using proper importance in oral home
scores brushing method care daily
Patient Ed #1 - -teach patient what plaque
Plaque/Toothbrushing STG: decrease plaque score is and how destructive it can
Scale Maxillary Right from 4.5 to 3 by next be.
appointment
-tell patient dangers of
sugary drinks and carbs and
STG: decrease bleeding
their effect on teeth.
score by 20% by next
appointment
Appointment 4:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction_______
Review Med/Dental LTG #3: patient will continue -educate patient on how
History plaque removal by reducing periodontitis is not
Plaque & bleeding score to 0 reversible, but its
score progression can be stopped.
Patient Ed #3 - Caries STG: teach patient the
Scale Mand right danger of periodontitis
quadrant
Plaque Free STG: decrease plaque score
Fluoride Varnish to 0
Set recall appointment
STG: decrease bleeding
score to 0
The prognosis is good. My patient is a young, twenty-year-old student and worker who does
not smoke. He has all his teeth, except for his wisdom teeth. He has no bone loss, and his
occlusion is a class 1. He works during the week and weekends and eats out at lunch and
sometimes during dinner. If he takes precautions with the drinks and food he ingests, and
stays on top of his oral home care, he can halt the periodontitis and gingivitis.
10. Supportive Therapy: State the suggestions made to patient regarding re-evaluation,
referral, and recall schedule. (Note: Include date of recall appointment below.)
Kevin should come back every 6 months to stay on top of plaque and calculus and should be
expected back by 4/1/2024. He needs referrals on suspicious areas 4-MOD, 5-DO, 29-DO, 30-
MOD.