Care Plan Student Name: Amanda Means
Patient: Date of data completion: 3-4-14
Date submitting plan: 3-11-14
Synopsis of Patient History
Age: 32
Sex: Male
Race: !ite
eig!t: N"A
P#op!$ %lass: 3
Pe#iodontal &$pe: %ase 2
1
st
Appointment 2
nd
Appointment 3
rd
Appointment
'lood P#essu#e: 1()"1)(* S&+ 1* Rt 1(("1),* S&+ 1* Rt
Pulse Rate: --* .3* #eg* N/ -)* .3* #eg* N/
Respi#ation Rate: 12* #eg* eas$* no#m*
N/
12* #eg* eas$* no#m*
N/
Pla0ue Sco#e: 21-2 3ai#
'leeding Sco#e: 2(1))2
Amount and gene#al location of pla0ue: Mode#ate and gene#ali4ed
%ont#ibuting facto#s fo# pla0ue #etention: %alculus* tobacco use* ca#ies* p#ost!esis* mout!
b#eat!ing
Current Oral Self Care Methods
Type Frequency
&oot!b#us!"b#us!ing
met!od
Manual* soft
'ac5 and fo#t!
2 x pe# da$
&oot!paste %#est 3D 6!itening
3loss None
Po6e# Assisted Appliances None
Rinses !ate7e# !is 6ife bu$s Sometimes
3luo#ide &oot!paste 2 x pe# da$
8t!e# None
Medical!ental History Summary"
11 #dentify any medical pro$lems that the patient mi%ht ha&e'
A#t!#itis* #!eumatoid a#t!#itis* osteopo#osis* fib#om$algia* and !e is cu##entl$ unde# t!e ca#e of a
p!$sician because in 2)1) !e !ad su#ge#$ to #emo7e bone cance# in !is #ig!t !ip1
21 #dentify any medical pro$lems that mi%ht complicate dental treatment( and )hat steps should $e
ta*en to minimi+e or a&oid their occurrence'
3ib#om$algia: allo6 patient to sit up#ig!t fo# 3-( min befo#e standing to a7oid di44iness1 Ma$ need to
limit c!ai# time in t!e supine position based on !o6 6ell t!e patient can tole#ate t!at position1
R!eumatoid a#t!#itis: %onside# semisupine position and limit time in t!e c!ai#1
31 ,ist any aller%ies that the patient has reported'
Patient is alle#gic to penicillin* ceclo#* and #emacade1 All cause #espi#ato#$ dist#ess and a #as! in t!e
patient1
41 ,ist medications currently ta*en $y the patient and the dental implications of each'
None
(1 !oes the patient smo*e or use to$acco products- 9es1
!ocument frequency and type of to$acco products used'
Patient dips and uses 1 can pe# da$1 :e !as been dipping fo# 1) $ea#s1
-1 .hen )as the patient/s last dental &isit-
.hat treatment )as rendered at this appointment-
/ast dental 7isit 6as on 2-13-14 fo# a sc#eening and an 3M;1 Patient also #ecentl$ !ad an uppe# pa#tial
made on 1-1<-141
<1 .hat is the chief complaint of the patient-
(Listed on M/D History)
&eet! cleaning and x-#a$s1
=1 ,ist any other medical information that you feel is pertinent to the treatment of this patient'
Patient does not cu##entl$ ta5e an$ medications fo# !is a#t!#itis* #!eumatoid a#t!#itis* o# !is fib#om$algia
6!ic! ma$ limit !is abilit$ to tole#ate !o6 long !e can la$ in t!e c!ai#1
,1 ,ist any other dental information that you feel is pertinent to the treatment of this patient'
Patient !as ne7e# !ad !is teet! p#ofessionall$ cleaned befo#e1 :e also seemed some6!at inte#ested in
smo5ing cessation1
1)1 Assess the patient/s current le&el of learnin% and state rationale'
Must be record in progress notes at every appointment.
/ea#ning /e7el: >na6a#e1 Patient is una6a#e about !is pe#iodontal disease o# !o6 dipping effects !is
o#al !ealt!1 :e is also not a6a#e about tilting t!e toot!b#us! at a 4( deg#ee angle to clean into t!e sulcus
and !e does not floss1
111 /ist all positi7e findings f#om $ou# data collection on t!e Chart of Positi&e Findin%s'
121 >se t!e positi7e findings to fill out t!e Chart of Patient 0eeds1
131 3o# e7e#$ p#oblem listed on t!e %!a#t of Patient Needs* state t!e lon% term %oals fo# dental !$giene
t#eatment t!at !a7e been establis!ed b$ t!e clinician and t!e patient1 >nde# eac! long te#m goal* state at
least 2 short term %oals t!at 6ill !elp t!e patient attain t!e long te#m goals1
141 State the clinician/s assessment of the possi$ility of the patient/s %oal attainment'
(Ex. excellent, good, fair, guarded, poor).
Explain your answer.
(Consider life-styles, financial ability, social/cultural background, etc.)
? belie7e t!e#e is a fai# c!ance t!at @@@@@@ 6ill ac!ie7e !is goals because !e seems 7e#$ inte#ested in t!e
ad7ice t!at ?A7e al#ead$ gi7en !im about !is o#al !ealt!1 :e !as 0uite a bit of o#al !$giene modification
a!ead of !im and se7e#al ca7ities t!at need to be filled* but ? belie7e 6it! t!e #ig!t info#mation and
positi7e encou#agement* t!at a mode#ate amount of pe#manent be!a7io#al modification 6ill be
ac!ie7able1
1(1 Outline t!e info#mation to be p#esented in t!e t!#ee Patient 1ducation Sessions'
?nclude t!e specific info#mation t!at 6ill be taug!t* t!e met!ods of p#esentation* and 6!at 7isual aids
6ill be used1 Submit on a sepa#ate page1
1-1 2eferrals" DDS fo# ca#ies1
1<1 2ecall Schedule" Since patient uses tobacco and !as pe#iodontitis* !is #ecall s!ould be 3-4 mont!s1
11' Chart of Positi&e Findin%s
Med!ent History
/ast p!$sical in 2))( Pt !as #!eumatoid a#t!#itis Pt doesnAt feel good about !is teet!
Pt !as !ad su#ge#$ Pt !as fib#om$algia &eet! a#e sensiti7e all t!e time
Pt !as osteopo#osis Pt is alle#gic to penicillin* %eclo#* Remacade %lenc!es !is teet!
Pt !ad pel7ic bone cance# >ses dip tobacco dail$ B1) $ea#sC :as an uppe# pa#tial
Pt !as a#t!#itis +ums bleed 6!en flossing D#in5s 1 D#1 Peppe# a da$
#ntra13tra Oral 13am
P!$s1 /imitations B!ad cance# cut out of #ig!t !ip boneC 8#al /ic!en planus
Scatte#ed ep!elids /ingual to#i
Ne7i D inc! left of #ig!t e$e Do#sal su#face of tongue pla0ue coated
'od$ t$pe Bp$5nicC Mout! b#eat!s Boccasionall$C
Red tonsils and pilla#s &ongue t!#ust
:ig! 7ault %#oss bite BE12 6"E2)C BE13 end to end 6"E21C
&!ic5ened buccal mucosa Bc!ee5 bitingC %lenc!es
4in%i&alPeriodontal Assessment
Mode#ate gene#ali4ed biofilm Pe#io1 %ase 2
'iofilm #etenti7e featu#es: calculus* ca#ies* p#ost!esis +en1 Ma#ginal and papilla#$ inflammation
P#edisposing facto#s: mout! b#eat!ing* tobacco
+en1 #ed* smoot! and s!in$* bulbous papillae
Slig!t gen1 #ed* smoot! and s!in$* #olled ma#gins
Recession EAs 2)*21*22*2=*2,
'leeding upon p#obing gen1 max1 and mand1 poste#io#
!ental Chartin%
Missing : EAs 1*4*=*1(*1-*1,*3)*31 4-< mm poc5et dept!s
Att#ition lo6e# ante#io#s
%a#ies: EAs 2*3*<*,*1)*12*14*1<*1=*2)*32
Recession: EAs 2)*21*22*2=*2, BfacialC
'leeding gene#ali4ed max1 and mand1 post1
2adio%raphs
Mild !o#i4ontal bone loss EAs 2="2, and E= a#ea
Mild 7e#tical bone loss EAs 1<"1=
%a#ies: >A*>/*//* and /A
Missing EAs 1*4*=*1(*1-*1,*3)*31
Other Findin%s
12' Chart of Patient 0eeds
Pro$lem 1tiolo%y Positi&e findin%s that
correlate )ith the
pro$lem5
Contri$utin% or
predisposin% factors
Patient 1ducation Topics Treatment Options and
Pre&enti&e Therapies
P#io#it$ E1
Pla0ue
'acte#ia
and poo#
o#al
!$giene
-Pla0ue sco#e: 21-2
-Mod1 gen1 pla0ue
-Mout! b#eat!ing
-&obacco
-#ed* bulbous papillae
-#olled* #ed gingi7a
-%alculus
-Pt doesnAt floss
-Pt b#us!es using a
bac5 and fo#t! motion
but doesnAt tilt t!e
b#istles at a 4( deg#ee
angle to clean into t!e
sulcus
LTG &!e pt 6ill #educe pla0ue sco#e
b$ 1( at e7e#$ appt1 until !e #eac!es
11121
!TG " Pt 6ill desc#ibe pla0ue
fo#mation b$ t!e second appt1
!TG # Pt 6ill co##ectl$ use t!e 'ass
b#us!ing tec!ni0ue b$ t!e t!i#d appt1
-Soft deposit #emo7al
-%alculus #emo7al
-Fncou#age p#ope# !ome ca#e on
a dail$ basis
-Antibacte#ial mout!6as!
-Patient education
P#io#it$ E2
Pe#iodontitis 'acte#ia
-Mode#ate gene#ali4ed
biofilm
-+ene#ali4ed #ed*
bulbous papillae
- Slig!t gene#ali4ed
#ed* #olled ma#gins
- Mild !o#i4ontal bone
loss EGs 2="2, and E=
a#ea
- Mild 7e#tical bond
loss EAs 1<"1=1
- Mout! b#eat!ing
-&obacco use
-Pt doesnAt floss
-Pt b#us!es using a
bac5 and fo#t! motion
but doesnAt tilt t!e
b#istles at a 4( deg#ee
angle to clean into t!e
sulcus
LTG &!e pt 6ill unde#stand 6!at
pe#iodontitis is and !o6 to !alt t!e
p#og#ession of !is pe#iodontal disease1
!TG " Pt 6ill be able to desc#ibe
6!at pe#iodontitis is b$ t!e second
appt1
!TG # Pt 6ill be able to demonst#ate
p#ope# H%G s!ape flossing b$ t!e t!i#d
appt1 and c!oose to floss e7e#$ ot!e#
da$ b$ 4-=-141
!TG $ Pt 6ill c!oose to floss
e7e#$da$ b$ 4-22-141
-Pe#iodontal deb#idement
-Regula# 3-4 mont! #ecall
-P#ope# !ome ca#e maintenance
-Antibacte#ial mout!6as!
P#io#it$ E3
%a#ies I
3luo#ide
'acte#ia*
poo# o#al
!$giene
-Radiog#ap!s s!o6
suspicious a#eas
-%a#ies can be seen
clinicall$ in t!e mout!
-Pla0ue sco#e: 21-2
-%alculus
-?##egula# dental
c!ec5-ups
-Pt doesnAt floss
-Poo# o#al !$giene
LTG &!e pt 6ill be able to explain
6!at ca#ies is* !o6 ca#ies a#e fo#med*
and !o6 fluo#ide !elps #educe t!e #is5
of ca#ies1
!TG " Pt 6ill be able to explain 6!at
causes ca#ies and !o6 ca#ies a#e
fo#med1
!TG # Pt 6ill be able to explain !o6
fluo#ide #educes ca#ies1
-At !ome fluo#ide #inses
-Refe# to DDS fo# ca#ies
-P#ope# !ome ca#e maintenance
-P#ofessional in office fluo#ide
t#eatments
Patient 1ducation Sessions
11 Patient Fducation &opic E1: Pla0ue
Long Ter% Goal &!e pt 6ill #educe pla0ue sco#e b$ 1( at e7e#$ appt1 until !e #eac!es 11121
!TG " Pt 6ill desc#ibe pla0ue fo#mation b$ t!e second appt1
!TG # Pt 6ill co##ectl$ use t!e 'ass b#us!ing tec!ni0ue b$ t!e t!i#d appt1
?1 !at is pla0ueJ
Pla0ue is a stic5$* basicall$ colo#less film of bacte#ia and food pa#ticles t!at fo#m on t!e teet!1
Pla0ue is t!e main cause of gum disease1
?t can !a#den into calculus Bta#ta#C if not #emo7ed p#ope#l$ eac! da$1
'acte#ia use t!e suga# found in t!e sali7a and pla0ue to feed on1
&!e bacte#ia p#oduce acid as a b$p#oduct 6!en t!e$ eat t!e pla0ue1 &!e acid attac5s ou# teet! and sta#ts t!e ca#ies
p#ocess* 6!ic! in time can fo#m a ca7it$ on t!e toot!1
??1 ill s!o6 patient !is pla0ue sco#e at e7e#$ appointment to !opefull$ ma#5 its decline 6it! e7e#$ appointment as stated
in !is goals1 ? 6ill also explain t!e scale 6e base ou# pla0ue sco#e on as 6ell as s!o6 !im 6!e#e t!e pin5 and pu#ple
a#eas a#e* and explain t!e diffe#ence in colo#1 Pin5 is less t!an 24 !ou#s old and pu#ple is olde# t!an 24 !ou#s old1
???1 P#ope# b#us!ing1
Discuss !o6 !is b#us!ing tec!ni0ue is not #eac!ing into t!e sulcus to clean off t!e pla0ue effecti7el$1
Fxplain t!e 'ass met!od of b#us!ing and !o6 using t!is met!od is effecti7e at #eac!ing into t!e sulcus 6!en t!e
b#istles a#e positioned p#ope#l$ at a 4( deg#ee angle1
?nst#uct patient on !o6 to position t!e b#istles at a 4( deg#ee angle into t!e a#ea bet6een t!e teet! and gums1 Ad7ise
patient to t#$ and b#us! 2-3 teet! in a 7ib#ato#$* !o#i4ontal motion and to b#us! fo# a full 2 minutes at least t6ice dail$1
ill demonst#ate b#us!ing on a t$podont1
Allo6 patient to demonst#ate on t$podont and t!en at t!e sin51
21 Patient Fducation &opic E2: Pe#iodontitis
Long Ter% Goal&!e pt 6ill unde#stand 6!at pe#iodontitis is and !o6 to !alt t!e p#og#ession of !is pe#iodontal disease1
!TG " Pt 6ill be able to desc#ibe 6!at pe#iodontitis is b$ t!e second appt1
!TG # Pt 6ill be able to demonst#ate p#ope# H%G s!ape flossing b$ t!e t!i#d appt1 and c!oose to floss e7e#$ ot!e# da$ b$ 4-
=-141
!TG $ Pt 6ill c!oose to floss e7e#$da$ b$ 4-22-141
?1 !at is pe#iodontitisJ
!en gum disease ad7ances be$ond t!e soft tissue into t!e bone* it is called pe#iodontitis1
&!is disease is i##e7e#sible* 6!ic! means t!at $ou# bod$ cannot #efo#m o# #eg#o6 t!e tissues and bone t!at $ouA7e
lost* but $ou can !alt t!e p#og#ession of t!e disease1
&obacco use* genetics* and poo# o#al !$giene can ma5e $ou mo#e susceptible to pe#iodontal disease1
??1 ill s!o6 patient 7isual aids of !ealt!$ pin5 gum tissue and #ed* inflamed* infected tissue1
???1 P#ope# flossing1
?t is #ecommended t!at $ou floss at least once a da$1
&a5e about 1= inc!es of floss and 6ind it a#ound $ou# middle finge#s* lea7ing about 2 inc!es fo# $ou# index finge#s
and t!umbs to 6o#5 6it!1
>se $ou# index finge#s and t!umbs to guide t!e floss bet6een t!e teet!1 3o#m a H%G s!ape 6it! t!e floss against
eac! toot!1 Mo7e t!e floss up and do6n a couple times to ma5e su#e $ou get all t!e pa#ticles loose1 +entl$ #emo7e
t!e floss f#om t!ose teet! and mo7e on to t!e next space1
>se $ou# middle finge#s as t!e spool t!e floss is on and 6ind it a6a$ f#om $ou to get a ne6 piece of floss fo# eac!
ne6 space1
Ma5e su#e to floss be!ind t!e last teet!1
?K1 ill demonst#ate p#ope# flossing on t$podont1 ill !a7e patient demonst#ate p#ope# flossing on t$podont1
31 Patient Fducation &opic E3: %a#ies and 3luo#ide
Long Ter% Goal &!e pt 6ill be able to explain 6!at ca#ies is* !o6 ca#ies a#e fo#med* and !o6 fluo#ide !elps #educe
t!e #is5 of ca#ies1
!TG " Pt 6ill be able to explain 6!at causes ca#ies and !o6 ca#ies a#e fo#med1
S&+ 2: Pt 6ill be able to explain !o6 fluo#ide #educes ca#ies1
?1 !at is ca#iesJ
%a#ies is anot!e# name fo# ca7ities1
%a#ies a#e fo#med b$ t!e bacte#ia in ou# mout!s feeding off of t!e suga# t!at 6e consume and t!e #esult is an acid
b$p#oduct t!at attac5s and b#ea5s do6n t!e enamel on ou# teet!1
&!e acid attac5s cause demine#ali4ation of t!e enamel1
8nce t!e deca$ b#ea5s t!#oug! t!e enamel* a ca7it$ is fo#med1
A dentist must t!en clean out all t!e deca$ and fill t!e toot!1
?f left unt#eated* t!e deca$ can dest#o$ a toot! all t!e 6a$ do6n to t!e ne#7e1
S!o6 patient 7isual aid of a ca7it$ and use !is #adiog#ap!s to s!o6 !im 6!e#e !is a#e1
??1 3luo#ide ?nst#uction
3luo#ide is found in man$ !ome ca#e aids and can also be applied as pa#t of $ou# dental t#eatment1 ?t !elps
st#engt!en $ou# enamel* ma5ing it mo#e #esistant to acid attac5s* and aids in t!e #emine#ali4ation p#ocess1
%#est P#o-:ealt! is an 8&% mout!6as! t!at !as fluo#ide in it1
S!o6 patient a sample of a mout! #inse 6it! fluo#ide in it and 6!e#e to find it on t!e label1
