Care Plan
Care Plan
Care Plan
Care Plan submission will use findings from included patient information.
Student Name Daniela Vargas
Patient Name Cobb, Jennifer Age 53
Chief Complaint: Tender gums
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:_____________
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:_______________
10. Missing teeth #1, #7, #10, #16, #17, & 10. Disease progression, shifting, supra-
#32 eruption, malpositioned teeth, &
food impaction
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 mild horizontal bone loss 1. Perio disease progression, tooth loss,
<15% mobility, caries progression, increased
2. Broken tooth - #3 plaque accumulation
2. Infection, caries, pain in tooth,
throbbing pain in neck, ear, jaw, and
head
3. Missing teeth: #1, #7, #10, #16, #17, 3. Disease progression, shifting, supra-
& #32 eruption, malposition teeth, and food
impaction
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. Missing teeth: #1, #7, #10, #16, #17, 1. Disease progression, shifting, supra-
& #32 eruption, malposition teeth, and food
2. Broken tooth - #3 impaction
3. Generalized posterior amalgam 2. Infection, caries, pain in tooth,
restorations throbbing pain in neck, ear, jaw, and
head, plaque accumulation, tooth loss
3. Overhangs, faulty restorations,
recurrent caries
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:_________________
Appointment 2:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
LTG #1: Plaque score of 0 by end
Plaque & bleeding of treatment
scores Introduce a new or
STG: Reduce plaque score to different brushing
st
Scaling 1 quad - UR 1 by next appointment technique
Discuss why brushing
Pt.ed: what is STG: Brush 2x a day by next 2x daily is important
plaque/toothbrushing appointment Inform Pt on fluoride
benefits and product
STG: Include fluoride into options
home dental care by next
appointment
Appointment 3:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
LTG #2: Reduce bleeding to 0% Educate Pt on
by end of treatment gingivitis/periodontal
nd
Scaling 2 quad - UL disease causes,
STG: Reduce bleeding by symptoms, &
Pt. ed: 50% by next appointment prevention
periodontitis/flossing Reiterate the
STG: Reduce bleeding by importance of
25% by next appointment flossing, introduce
techniques,
STG: begin to floss 1x daily supplemental aids,
by next appointment how-to, & time
availability to floss in
Pt daily schedule
Speak about
importance of
flossing, frequency &
types
Appointment 4:
Plan for Treatment: Goals: Plan for Education and/or Oral
______________________________________________________Hygiene Instruction________
LTG #3: No calculus formation Attend dental office
Scaling 3rd quad -LL by end of treatment every 3-4 months
until periodontal
Pt.ed: frequent dental STG: reduce calculus status is improved.
visits/ calculus formation at home Continue dental care
to every 6 months to
STG: attend office every 6 prevent excessive
months calculus or caries
formation.
STG: attend office every 3-4
months
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)
Based on the patient’s existing factors, her overall prognosis is good. She has adequate self-
care ability, as well as control of etiologic factors. She also has less than 25% attachment loss
and is classified as a class I for furcation involvement. She is 53 years of age, has fair home
dental care, and her social history does not allow her much time to give her oral cavity the
attention it needs. She exhibits fair biofilm control and history of infrequent dental visits.
May experience gingival enlargement because of medication taken for seizures. She is
missing 6 teeth and has a broken tooth with radiographic decay. She experiences generalized
mild horizontal bone loss, generalized periodontal pockets in remaining teeth, and localized
recession. She is a full-time mother and housekeeper, works part-time, and actively
participates at her local church. Therefore, she has a busy schedule that doesn’t allow her to
keep up with her oral health.
10. Supportive Therapy: State the suggestions made to patient regarding re-evaluation,
referral, and recall schedule. (Note: Include date of recall appointment below.)