Download care plan - Ton`s Portfolio

Care Plan
Student Name _____Thu Ton_______
Patient _________
Date of data completion _4/8/13__
Date submitting plan
_4/10/13___
Synopsis of Patient History
Age:
Sex:
Race:
Weight:
Prophy Class:
Periodontal Type:
Blood Pressure:
Pulse Rate:
Respiration Rate:
Plaque Score:
Bleeding Score:
21
Male
Asian
140
3
II
1st Appointment
108/65, right, WNL
60, +2, regular, WNL
17, regular, easy,norm
WNL
2 – Fair
10.9%
Amount and general location of plaque:
Predisposing factors for plaque retention:
2nd Appointment
110/75, right, WNL
57, +2, regular, WLN
16, regular, easy, norm
WLN
3rd Appointment
Slight generalized
Malpositioned teeth, 3rd molars
Current Oral Self Care Methods
Toothbrush
Toothpaste
Floss
Power Assisted Appliances
Rinses
Fluoride
Other
Type
Soft toothbrush
Crest/Oral B
Floss picks
None
None
None
None
Frequency
Twice daily
3x/week
None
None
None
Medical/Dental History Summary:
1.
Identify any medical problems that the patient might have.
Patient has good medical history.
2.
Identify any medical problems that might complicate dental treatment, and what steps should be taken to
minimize or avoid their occurrence.
Because he has a good health, so there is not anything to minimize or avoid during treatment.
3.
List any allergies that the patient has reported.
He doesn’t have any allergies.
4.
List medications currently taken by the patient and the dental implications of each.
The patient is not taking any medication.
5.
Does the patient smoke or use tobacco products?
Document frequency and type of tobacco products used.
The patient doesn’t smoke or use tobacco products.
6.
When was the patient’s last dental visit?
What treatment was rendered at this appointment?
He does not remember.
7.
What is the chief complaint of the patient?
(Listed on M/D History)
Cleaning
8.
List any other medical information that you feel is pertinent to the treatment of this patient.
None
9.
List any other dental information that you feel is pertinent to the treatment of this patient.
He should visit the dental office to extract impacted third molars, to treat slight horizontal bone loss,
root anomalies, caries.
10.
Assess the patient’s current level of learning and state rationale.
Must be record in progress notes at every appointment.
We discussed about brushing in the second appointment. I recommended him that he should handle
toothbrush at 45 angles and use vertical and horizontal brushing technique together. LL: aware, selfinterest. He was interested in it and said he will practice at home.
11.
List all positive findings from your data collection on the Chart of Positive Findings.
12.
Use the positive findings to fill out the Chart of Patient Needs.
13.
For every problem listed on the Chart of Patient Needs, state the long term goals for dental hygiene
treatment that have been established by the clinician and the patient. Under each long term goal, state at
least 2 short term goals that will help the patient attain the long term goals.
14.
State the clinician’s assessment of the possibility of the patient’s goal attainment.
(Ex. excellent, good, fair, guarded, poor).
Explain your answer.
(Consider life-styles, financial ability, social/cultural background, etc.)
Good. He has good life-styles with good medical health. He is student and he is working in part time
job. Therefore, he can afford for dental treatment.
15.
Fill out the Appointment Manager with the actual time it took you to do the patient’s paperwork.
Estimate the amount of time needed to do patient education and scaling. Keep in mind you will do
three patient education sessions and only scale one quadrant per appointment.
16.
Outline the information to be presented in the three Patient Education Sessions.
Include the specific information that will be taught, the methods of presentation, and what visual aids
will be used.
11. Chart of Positive Findings
Med/Dent History
None
Intra/Extra Oral Exam
Scattered acnes, 1-2 mm, irregular, etiol: bacteria
Nodule, red color, on the nose, 2 cm, irregular, poor defined, etiol: trauma
Eye: near sight, etiol: developmental
Submandibular: bilateral lymph nodes,1-2 mm, etiol: allergy with pollen
TMJ –sound: poping both sides, etiol: trauma
Linea alba, 3 cm in length, irregular, etiol: bite cheek
Oral habit: clenching, grinding
Occlusion: Molar R-I, L-I; Canine R-I, L-I; open bite: #6,7,10,11; cross bite: #13,19,20
Gingival/Periodontal Assessment
Generalized scalloped. Generalized red on maxillary and mandible, especially red on lingual
madibular molars. Generalized edematous on maxillary and mandible. Smooth and shiny surface
texture on mandible and maxillary. Generalized bulbous, rolled margins on facial and lingual
mandible and maxillary
Recession: #3, 14, 19 1mm
Bleeding: generalized posterial maxillary and mandible
Pocket depth: generalized 4mm: #3,4,14,15,16,17,18,19,20,29,30,31,32(facial);
#4,13,14,16,17,18,29,30,32 (lingual)
Bleeding index: 10.9%, Plaque score: 2 (fair)
Periodontal case: type II
Dental Charting
Partially erupted: #17, impacted:#1, 17,32
TCR #30,31
Linguoversion: #13,20
Torsiversion distal to mesial: #7,10
Sealant: #3,14,19
Amalgam: #18
Attrition: #22,23,24,25,26
Open contact: #8,9
Endodontic therapy: #9
Suspicious area: #30M, 29D
Radiographs
Mild horizontal boneloss: #14,15,18,19,20,24,25
Root anomalies: #16,17
Calculus: #19M
Caries: #4D, 19D
Other Findings
12. Chart of Patient Needs
Problem
Etiology
Positive findings
that correlate with
the problem
Slight generalized
biofilm, plaque
score (2-fair),
bleeding: 10.9%,
mild horizontal
bone loss, localized
recession
Generalized
edematous, red,
smooth and shinny,
bulbous, rolled
gingival
Localized horizontal
bone loss
Bleeding upon
probing
Contributing or
predisposing factors
Patient Education Topics
Treatment Options and
Preventive Therapies
Priority
_1_Plaque_
Bacteria
Malpositioned teeth,
impacted teeth
Lacking rinsing
frequently
-Definition of Plaque
- Instruction of brushing,
flossing, mouth rinse, caries,
periodontitis
Biofilm removal
Scaling
Patient education
Malpositioned teeth,
impacted teeth
Poor oral hygiene
Lack of regular dental
visit
-Definition of Periodontitis
- Instruction of brushing,
flossing
- Explain the importance of
regular dental visit
-Schedule appointment for 6
months
- Flossing everyday
-Mouth rise everyday
Biofilm removal
Scaling
Patient education
Dental Charting
Malpositioned teeth
Poor oral hygiene
Patient education about
using fluoride at home.
Office fluoride treatment
Sealants
Developmental Dental charting
Malpositioned teeth
Caries process
Prevention
Xylitol
Fluoride
Taking a lot of candy
Malpositioned teeth make it
hard to clean areas
Problem related to not
extracting third molars
Priority
Bacteria
_2_Periodontitis_
Bacteria
Priority
_3_Caries
prevention_
Priority
_4_Third
molars_
Refer to DDS for extraction
Patient Education Goals
Problem – Plaque
Long Term Goal – Mr. will maintain a low plaque score by continuing to brush and floss daily by 10/2013
STG – Mr. will know what plaque is and use disclosing solution to find plaque in her mouth by 4/15/13
STG – Mr. will demonstrate proper sulcular brushing technique by 3/27/13
STG – Mr. will lower than 2 in her plaque score at each appointment. Flossing and brushing are solution.
Problem – Periodontitis
Long Term Goal – Mr. Nguyen will halt the progression of her periodontal disease by 10/2013 via measuring pocket dept, recession, lower bleeding
score, reducing bone loss in radiographic. Mr. Nguyen will achieve healthy gingival tissues as shown by an improved soft tissue description and a
bleeding score of less than 10.9% by 10/2013
STG – Mr. will know how to define periodontal disease by 4/15/13
STG – Mr. will show an improvement in pocket depths by 10/2013
STG - Mr. will demonstrate to floss by 4/15/2013
STG – Mr. will decrease his bleeding percentage by 10.9% at every appointment until 5% o less is maintained
STG – Mr. will correctly demonstrate brushing technique by 4/15/13
STG – Mr. will keep regular appointment (every 6 months) with the dental office for preventive periodontal therapy. Mr. Nguyen will
schedule a preventive appointment for 6 months after the completion of her current dental hygiene care plan
STG – Mr. will know how to brush by sulcular technique
Problem – Impacted third molars
Long Term Goal – Mr. will be made appointment with DDS to have 3rd molars extracted
STG – Mr. will discuss the importance to extract the third molars to maintain oral health care at home
STG – Mr. will schedule an appointment with DDS by 4/22/13
Problem – Caries prevention
Long Term Goal – Mr. will be made appointment with DDS to treat caries #29, 30
STG – Mr. will explain how caries develop by 4/22/13
STG – Mr. will choose to use fluoride treatment at home by 4/22/13
CARE PLAN APPOINTMENT MANAGER
ASSESSMENTS
Health History
Intra/Extra Oral Exam
Gingival/Periodontal
Dental Charting
Plaque score
Radiographs
Informed Consent
1st Appt.
minutes
needed
30 min
45 min
55 min
35 min
10 min
2rd Appt.
minutes
needed
10 min-update
3th Appt.
minutes
needed
10 min-update
4th Appt.
minutes
needed
10min-update
10 min
10 min
10 min
7th Appt.
10 min
PT. ED. SESSIONS (30 min. in patient education room)
Brushing
Plaque
Flossing
Periodontitis
Caries
Fluoride
10 min
10 min
10 min
TREATMENT
Scale maxillary right
Scale maxillary left
Scale mandibular right
Scale mandibular left
Plaque free/polish
Fluoride
other
SUB-TOTAL APPT.
5th Appt.
minutes
needed
Session 1
5 min
5 min
5 min
15 min
Session 2
Session 3
2 min
2 min
2 min
4 min
10 min
10 min
60 min
60 min
60 min
60 min
30 min
10 min
3:35
3:23
3:23
1:30
Total Time:
11:11
Referrals:
Explanation:
1.DDS
Third molars need to be extracted, treatment
for caries
2.
3.
4.
5.
Recall: I will put her on 6 months recall
Improving soft tissue, lower bleeding score
Patient Education Outline
Preparation
- Prepare pt ed room
- PPE (gloves, mask)
- Pt chart and x-rays out
- Disclosing solution, swab, cup
- Toothbrush, toothpaste
- Visual aids
- Typodont
- Floss
Session 1
At the table
Discuss LTG and STG
LTG– Mr. will maintain a low plaque score by continuing to brush daily
STG – Mr. will know what plaque is and use disclosing solution to find plaque in her mouth
STG – Mr. will demonstrate proper sulcular brushing technique
STG – Mr. will lower than 2 in her plaque score at each appointment. Flossing and brushing are solution
Plaque:
- Definition Plaque: Plaque is bacteria which develops on the teeth easily. It is sticky. It forms every 24 hours and can remove by brushing and
flossing.
- Show patient visual aid to distinguish between clean teeth and plaque coated teeth.
- Show patient his plaque score. His plaque score is 2 – fair
- Show where the disclosing solution stained on his teeth
- State the diseases are related to plaque: gingivitis, periodontitis, caries.
- Discuss plaque removal techniques: tell his that brushing and flossing are the best way to remove plaque. I will be modifying his technique to
make it more effective
Brushing instruction:
- Discuss brushing technique : bass method, modified stillman method and explain why they are important
- With typodont, brush at 45 degree angle to long axis of the tooth with slight pressure.
- Have patient demonstrate on typodont (help as needed)
At the sink:
- Give patient toothbrush
- Help patient to brush with modified technique if needed
- Disclose patient to determine how well she did
- Modify technique if necessary
Back to table:
Ask questions to check for learning
- What is plaque?
- Do you still remember what sulcular brushing is?
- Do you have any questions?
Establish partnership with patient:
I want to help you have a better oral health. I hope I can give you a professional cleaning, useful information for taking care of your teeth. Your
participation is very important to achieve the goal.
Patient Education Outline
Preparation
- Prepare pt ed room
- PPE (gloves, mask)
- Pt chart and x-rays out
- Disclosing solution, swab, cup
- Toothbrush, toothpaste
- Visual aids
- Typodont
- Floss
Session 2
Review what we mentioned last session: what plaque is, technique of brushing
At the table:
Discuss LTG and STG
LTG – Mr. will halt the progression of her periodontal disease by 10/2013 via measuring pocket dept, recession, lower bleeding
score,
reducing bone loss in radiographic. Mr. will achieve healthy gingival tissues as shown by an improved soft tissue description and a bleeding score of
less than 10.9%
STG – Mr. will know how to define periodontal disease
STG - Mr. will demonstrate to floss
STG – Mr. will decrease his bleeding percentage by 10.9% at every appointment until 5% o less is maintained
STG – Mr. will keep regular appointment (every 6 months) with the dental office for preventive periodontal therapy. Mr. will schedule a
preventive appointment for 6 months after the completion of her current dental hygiene care plan
Periodontitis
- Definition periodontitis: Periodontitis is caused by bacteria found in dental plaque. It is irreversible if untreated and poor oral hygiene.
Periodontitis is caused of teeth loss.
- Show patient visual aid how periodontal disease looks like. Show the picture in the flip chart to compare periodontal tooth and healthy tooth.
- Show his x-ray mild generalized bone loss
- Show dental charting with evidence of CAL
Flossing instruction
- Type of flossing: Nylon (multifilament) and PTFE (monofilament)
- It is used to remove plaque between the teeth
-
-
Flossing technique: winding 18 inches of the floss around each middle finger, leaving an inch or two of floss to work with. Holding the floss
tautly between your thumbs and index fingers, slide it gently up and down between the teeth. Gently curve the floss around the base of each
tooth. Use clean sections of floss to move from tooth to tooth. To remove the floss, use the same back and forth motion to bring the floss up
and away from the teeth. (use typodont)
Allow patient to try new technique on typodont
At the sink
- Give patient floss using new technique, watch and help as needed
- Disclose and help patient to evaluate flossing
- Modify technique if necessary
Back to table
Ask questions to check for learning
- Definition periodontitis
- Do you know the importance of flossing?
- Do you any questions?
Establish partnership with patient
I hope all of things that we discussed today will help you to take care of your oral health. It is very important that you practice at home and ask if you
need to help.
Patient Education Outline
Preparation
- Prepare pt ed room
- PPE (gloves, mask)
- Pt chart and x-rays out
- Disclosing solution, swab, cup
- Toothbrush, toothpaste
- Visual aids
- Typodont
- Floss
Session 3
Review what was talked about last 2 sessions: what the plaque is, brushing, flossing, periodontitis
At the table
Discuss LTG and STG
LTG – Caries prevention
STG – The patient will be known how to use fluoride at home
Caries
- Definition caries: Caries is tooth decay or cavity. Tooth decay happens when acids wear away the tooth ‘s hard surface layer. It will be cause
holes in the tooth surface. These are called cavities.
- Show patient visual aids about carious lesions. Compare between healthy teeth and cavities.
- Use dental chart, show him the current caries
- Some another factors are caused of caries: lacking of using fluoride, poor oral hygiene by flossing, bushing, rarely removing stains
There are many methods to help prevent caries such as sealant, xylitol, flossing, brushing, mouth rinse, and diet control and fluoride.
Fluoride
Some benefits for using fluoride once daily at home
- Fluoride promotes remineralization of tooth
- Fluoride helps to prevents caries
Suggest patient to use products that contain fluoride: fluoride toothpaste, fluoridated drinking water, gel.
Ask the patient some questions:
- Can you tell me what caries is?
- What is fluorides?
- Which products can we find fluoride?
- Do you have any questions?
Establish partnership with patient:
I hope the information that I gave you is helpful to prevent oral diseases and caries. It has been great working with you. Working together we can
improve your oral health. Thank you for your cooperation. See you again in 6 months.