first year care plan

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CARE PLAN - Year 1 – Fall Semester Care Plan submission will use findings from included patient information. Student Name: Gabby Howe Patient Name: ------------

Age: 43

Chief Complaint: Bad breath and stained teeth 1. Medical History: (list any positive medical history findings from the medical & social history. Correlate the finding places the patient at risk for.) Medical History Findings Recent diagnosis of Rheumatoid Arthritis

At Risk For:______________ Possible cartilage loss; possible TMJ complications; motor control issues;issues with grasping items; periodontitis

Prescribed Medication: Methotrexate

Dry mouth; intraoral ulcers; swelling or inflammation of the mouth; bleeding of the gums; joint pains

Infrequent medical checkup:

systemic disease

Smoking for 26 yrs; 1 pack daily:

oral cancer; staining; leukoplakia; gingivitis; tooth loss; nicotine stomatitis; buccal mucosa staining; periodontitis; dry mouth; bone loss

Consumes alcohol on weekend: Periodontitis; oral cancer; dry mouth; slower immune response demineralization, plaque build up; possibility of caries; bad nutrition 2. Dental History: (List past and/or present dental disease, the chief complaint, and the present oral hygiene habits. Correlate the effects on periodontal diagnosis, and/or care) Poor diet, fast food:

Dental History Findings Smoking for 26 years; bad breath & staining

At Risk For:_____________ oral cancer; bone loss; inflammation;

leukoplakia; tooth loss; nicotine stomatitis, buccal mucosa staining; gingivitis; periodontitis Doesn’t floss:

Caries; low plaque score; periodontal disease; bleeding;

Discolored and coated tongue:

Halitosis; bacteria;

10 years since last appointment:

Unmaintained oral health; periodontal disease; caries; broken restorations; oral cancer

Poor diet:

demineralization; plaque bacteria; caries;

3. Oral Examination: (List the positive findings, habits, and awareness. Correlate the effects on periodontal diagnosis) Oral Examination Findings

At Risk For:___________

Generalized slight nicotine stomatitis in hard palate:

oral cancer; inflammation of minor salivary glands

Generalized moderate to heavy brown stain on buccal mucosa:

oral cancer

4. Periodontal Examination: (make a statement regarding the color, contour, texture, consistency, general biofilm locations, biofilm retentive features, predisposing factors to biofilm retention, overall pocket depths, bone loss, make reference to location of bleeding sites, etc.) Gingival Statement: Generalized severe gingival enlargement, fibrotic, whitened marginal, papillary redness, with rolled margins, stippled attached gingiva Generalized maxillary and mandibular probing depth of 5-6 mm with localized bleeding Calculus classification: generalized moderate subgingival calculus and moderate stained biofilm, class 4 a.

Periodontitis Stage: 3 - Periodontitis Grade: C


Plaque Score: 74% /Evaluation of plaque score: FAIR


Bleeding Score: 16% /Evaluation of bleeding score: GOOD

5. Dental Charting Examination: (List all findings from dental charting exam. Examples are caries, attrition, midline position, occlusion, abfractions, etc. Correlate to effect on periodontal diagnosis, progression, and/or care) Dental Charting Findings: For:___________________ Class 1, right/left; slight mandibular anterior crowding: Broken tooth colored restorations: 3-MO, 5MOD:

At Risk Caries; periodontal disease; plaque continued breakage; exposed root tips ; caries; possible infections

6. Radiographic Findings: (List the conditions such as crown to root ratio, bone loss, condition of interproximal bony crests, thickened lamina dura, calculus, and root resorption) Radiographic Findings:___________________________At Risk For:_________________ 15-30% horizontal bone loss (generalized):

Possible tooth movement; loss of additional teeth; periodontal disease

Missing Teeth: 1, 16, 17, 19, 32:

distal drifting for teeth #’s 2,15, 18, 20, 31, supravertion for tooth #’s 15, 13

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:_________________ Class 4 calculus classification: Poor dental hygiene periodontal disease: stage 3/class C:

Poor dental hygiene & smoking

Hard palate nicotine stomatitis:


Brown stain on buccal mucosa:


Missing and damaged teeth: 15%-30% horizontal bone loss

Poor dental hygiene/ infrequent visits Periodontal Disease

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 at least 2 short term goals. Appointment 1: Plan for Treatment: Goals: Plan for Education and/or Oral ______________________________________________________Hygiene Instruction Medical and dental history with vital signs Radiographs-FMX Intra/Extra Oral Exam Dental Charting Periodontal assessment Plaque and bleeding score Informed consent

HIPAA Patient education session Appointment 2: Reduce biofilms for arresting periodontitis within the next

Schedule appointment for next month and reduce plaque score Educate patient on staining, periodontitis, and bad breath (reasons/causes for this: use flipbook)

year. Introduce idea of cessation Learn new brushing and flossing technique

Explain how we can reduce plaque score and why it will help Demonstrate/ teach best brushing technique for patient

Plan for Treatment: Goals: Plan for Education and/or Oral ______________________________________________________Hygiene Instruction Review medical and dental history Vital signs Periodontal assessment Plaque and bleeding score Scale mandibular arch, right and left quadrant Patient education session discuss patient having tooth #3 and #5 repaired

Introduce flossing Continue reduction of biofilm Ask about cessation goals/achievements

Demonstrate proper flossing: make a goal to floss weekly. Review brushing technique

Schedule 3 month appointment: Get reduction of plaque score to 20%

Appointment 3: Plan for Treatment: Goals: Plan for Education and/or Oral ______________________________________________________Hygiene Instruction______ Review medical and dental history Arrest periodontitis: At home care Vital signs aids Periodontal assessment Plaque and bleeding score Cessation: 10 cigarettes a day Scale Maxillary arch, right and left Explain continuing care for quadrant periodontitis to assure arrest Patient education session

Make appointment for patient’s Referral for assessment on tooth # 3 & #5 repairs

intraoral lesions for oral cancer before next visit

Appointment 4:

Schedule repair for tooth # 3 & #5 before next visit Introduce a fluoride rinse to patient’s routine if flossing properly

Increase flossing from weekly to daily

Plan for Treatment: Goals: Plan for Education and/or Oral ______________________________________________________Hygiene Instruction__ Review medical and dental history Vital signs Reduction to one pack a week Periodontal assessment Plaque and bleeding score Flossing twice daily Patient education session Use of fluoride mouth rinse: how’s that going? Keep reduction of plaque score Complete arrest of periodontitis in Aim for regular appointments/ next 6 months check ups

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 patient’s prognosis depends on the patient’ s compliance. In order to succeed, the patient must actively perform at home care to specified goals. If treatment is avoided by the patient, she may see, progression of periodontitis, bone loss, possible development of oral cancer, tooth decay, and worsening symptoms for her Rheumatoid Arthritis. By following the treatment plan, the patient will be able to: arrest periodontitis, get rid of inflammation, improve stains, reduce risk of oral cancer, and improve her overall health. 10. Supportive Therapy: State the suggestions made to patient regarding re-evaluation, referral, and recall schedule. (Note: Include date of recall appointment below.) Patient received referrals concerning: restoration repair, and possible replacement of tooth #3 & #5, referral to a periodontist for arresting periodontic disease, and a referral to an oncologist to assess oral cancer. 12-21-20 – Return in one month after periodontist referral for routine cleaning.

1-11-21 – Schedule next cleaning one month after this appointment 2-11-21 – Schedule repairs for tooth #3 & #5 before next appointment in 3 months 5-11-21 – Schedule next 3 month visit, schedule oncologist referral, assess tobacco cessation

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