Date: 10.14.

16
Student Name: Hanna Feller
Patient Name: Daniel M.
DOB: 10/03/1980
Medical History & Medications:
Pt is in good health and is not currently
taking any medications and did not report
any allergies.
DMACC
Dental Hygiene
Treatment Plan
ASA Physical Status Dental History: Occlusion:
Classification: Pt went to his general DDS regularly as Bilateral class I
Class I a child but stopped going once
he got into his twenties. Pt does not
have a regular dentist currently and has
been coming to the DMACC Clinic
since 2015. His last dental appt. was
four years ago in the fall of 2012. Tooth
#30 was extracted because of decay. Pt
has no history of orthodontic tx. A full
mouth series was exposed Februrary
2015 because the pt had qualified for
boards.The pt has no chief complaint
and was just interested in finishing his
SRP treatment. Pt has four third molars
that are missing. Pt has an occlusal
amalgam on tooth #3 due to decay. He
has amalgam restorations on: OB #14,
MODL #15. Tooth #14 has a fracture
and the distal cusps of #14 and #15 were
visibly broken down. Pt has moderate
staining from drinking dark soda on the
lingual surfaces of his anterior teeth. Pt
reports lots of sensitivity while getting
his teeth cleaned and during probing. Pt
has had local anesthetic in past
appointments.

Developmental Abnormalities & Defects: Restorative Problems: Other: Radiographic Evidence:

Pt presens with bilateral cheek bite,
bilateral sloughing and bilateral mandibular
tori.
Restoration on #14 is fatal due
to fracture, causing pt pain
when eating.
1
no A full mouth series w/ sensor was
exposed in February 2015 per
DDS. Dx wasn't recorded just
possible quialifying quads for
boards. His most recent
 appointment, RDH Miller found
radiograpohic evidence of
possible decay on #7, #10 & #14.

Risk Factors are as follows (be specific).

1. Systemic Health: 3. Caries high risk
CVD: no Sugar Intake: high- 6x daily
Diabetes Mellitus: no Streptococcus Mutans Count: I suspect this patient's bacteria
count is high
Respiratory Disease: no Plaque-Removal Ability: fair with normal dexterity
Osteoporosis: no Socioeconomic Status: normal
Preterm Low Birth Weight: no Plaque Retentive Factors: Pt does not have any dexterity
limitations, however he does not
spend the time needed on his teeth
to have a healthy oral cavity. Pt
has deep pockets that allow
baterica to build-up. He also
several restorative problems that
cause plaque to attach and
possible recurrent decay could
form.Pt smokes & is not
interested in quitting.
Behavioral Status: Pt is interested in returning for Fluoride History: Pt grew up in a small town in
3 mo. SPM appts to keep his Iowa with regular exposure to
gums healthy. He said that it fluoridated water. Since beginning
had been a 2 year process to his treatment at DMACC he has
get his cleaning completed. He had fluoride treatment once a
was very receptive to the year. He currently lives in an area
dental knowledge that was with a fluoridated water supply.
given to him & was eager to He also uses a fluoride toothpaste
improve his oral health. Pt was once daily.
very interested in getting his
restorations fixed, and asked
good questions about
homecare as well as how to
prevent further destruction of
his bone health.
Psychosocial Status: normal Past & Present Caries Activity: Pt has existing amalgam
2
 restorations that could possibly
have reccurrent decay. RDH
Miller found possible beginning
stages of cavitation on tooth #7 &
#10.
Medication Considerations: none Other: none
Other: none
4. Periodontal Disease: generalized mod-se ggvts present
2. Oral & Pharyngeal Cancer: no (host environmental risk factors/indicators)
Tobacco Use: Pt smokes 1 pack of cigarettes Previous History of Disease: Pt has received SRP treatments in
a day in addition to chewing the past due to deep pocket depths
tobacco and slight bone loss.
Race: Caucasian Classification of Disease(s): Generalized moderate
Alcohol Use Pt states that he usually drinks Clinical Attachment Loss: Pt did not present with any areas
on weekends with family & of recession at this time.
friends Generalized 3-4 mm pockets,
localized 5 mm pockets.
Sun Exposure: Light-moderate, pt usually Stress Factors
works indoors laying
hardwood floors, but spends
weekends outdoors.
Pathology: Pt presens with bilateral cheek PHP: 2.6
bite, bilateral sloughing and
bilateral mandibular tori.
Other: none PBI: 3.7%
Deposits Classification: Class IV
Bacterial Pathogens: I suspect that the pathogens, S.
Mutans & P. Gingivalis are high
in this patient's oral cavity.
Tobacco Use: Pt smokes 1 pack of cigarettes per
day & also chews tobacco
Glycemic Control no
Inherited Risk Pt was unsure if parents or
siblings have been diagnosed with
periodontal disease
Other: none

3
Date: 10.14.16
Student Name: Hanna Feller
Patient Name: Daniel M.
DOB: 10.03.1980

Diagnostic Decision Making

Eight Human Needs Related to Oral Health & Disease
Assessment (check signs and symptoms present)
1. Wholesome Facial Image 5. Freedom from Head and Neck Pain
Teeth Gingiva Facial Profile Extra-/intra-oral pain or sensitivity
Breath Other: Other:

2. Freedom from Anziety/Stress 6. Biologically Sound & Functional Dentition

Reports or Displays: Reports difficulty in chewing
Anxiety about proximity of clinician confidentiality or previous Presents with:
dental experience. Defective restorations Ill-fitting dentures, appliances
Oral Habits Substance Abuse Teeth with signs of disease Abrasion erosion
Missing teeth Rampant caries
Concern about: Other:
Infection control, fluoride therapy, fluoridation, mercury toxicity

3. Skin & Muccous Membrane Integrity of Head & Neck 7. Responsibility for Oral Health
Extra/intra-oral lesion Pockets greater than 4mm Plaque and calculus present
Swelling Attachment loss greater than 4mm Inadequate parental supervision of oral health care
Gingival inflammation Xerostomia No dental exam within the last 2 years
Bleeding on probing Other: Other: Pt only brushes once a day

4. Protection from Health Risks 8. Conceptualization & Understanding

BP outside of normal limits Need for prophylactic antibiotics Has questions about DH care and/or oral disease
Potential for injury Risk Factors Other:
Other:

4
5
Date: 10.14.16
Student Name: Hanna Feller
Patient Name: Daniel M.
DOB: 10.03.1980

1. Initial Review Statement (chief concern, patient wants and expectations):

Daniel is a 36-year-old male. His reason for treatment is SRP. He has been a previous boards patient for 2 family members in the past and was in the
process of completely his treatment. His first appoint was in January of 2015 and he recently finished his treatment October 2016. Pt had no chief
complaint but just wanted to complete his treatment. Daniel understood why he needed to have these long appointments but was ready to have his
oral cavity in a healthy state. Pt is self employed as a construction worker, laying hardwood floors. His socioeconomical status is a normal, only
supporting himself and his girlfriend. Daniel reported drinking more than 4 dark sodas a day and has noticed some staining. He only brushes once a
day and does not regularly floss. Pt reported being extremely sensitive during his cleanings , even while measuring probing depths.

2. Hypotheses (differential diagnosis):

Bleeding on probing
Gingivitis
Periodontitis
Sensitivity/tooth pain
Halitosis
Missing teeth
Missing restorations
Broken teeth
Staining
Moderate plaque
Tenacious calculus
Lack of dental knowledge/ requires dental health education: disease & etiology
Lack of efficent homecare
Limited finances
Local anesthetic needed for future SRP appointments due to sensitivity
Oraqix might be needed if there is tooth sensitivity during SPM appointments

3. Inquiry Strategy:
Review health history
Review dental history
Extra-oral & intra-oral screening exams
CHX rinse
Hard tissue charting
Full mouth periodontal assessment
6
PHP
Pt education
PBI
Radiographs
Before & after introral/extraoral photos
Depoist classification
Caries risk assessment
Local anesthetic because of sensitivity
4 quads of SRP tx
In depth pt education about etiology of periodontal disease & stress importance of homecare/ more pt education at end of each appointment
6 week re-evaluation
Polishing
Flossing
Fluoride varnish per pt request
3 month SPM
Prescription for CHX rinse

7
Date: 10.14.16
Student Name: Hanna Feller
Patient Name: Daniel M.
DOB: 10.03.1980

4. Dental Hygiene Diagnosis (list the human need not met, then be specific about the etiology & signs & symptoms evidencing a defect):

Unmet Human Need Etiology Signs & Symptoms

1. Wholesome Facial Image
a. Teeth Lack of routine dental care, lack of plaque Staining, missing teeth, broken teeth, heavy
removal due to poor hom ecare, lack of dental tenacious calculus, moderate to heavy plaque
knowledge accumulation
b. Breath Ineffective plaque removal due to poor home care, Halitosis
lack of dental knowledge, inefficient tooth
brushing technique
c. Gingiva Lack of routine dental care, lack of flossing Gingivitis, periodontal disease, bleeding on
regularly, lack of brushing tongue probing
2. Freedom from Anxiety & Stress
a. Anxiety about receiving local anesthetic Lack of dental knowledge, lack of positive dental Pt does not want to be in any pain during
experiences treatment & knows local anesthetic will prevent
any pain
b. Oral habits Lack of dental knowlegde, lack of correct Pt does not use correct brushing technques, pt
brushing techniques, lack of flossing regularly does not floss regularly
c. Substance Abuse Lack of dental knowledge, excessive consumption Staining, missing teeth, moderate to heavy plaque
of caffiene, pt lack of knowledge of smoking accumulation
effects on oral cavity
3. Skin & Mucous Membrane Integrity of the
Head & Neck
a. Gingival Inflammation Lack of ineffective plaque removal, lack of routine Bleeding on probing, erythematous
dental care, lack of IP cleaning, lack of knowledge
of periodontal disease & smoking/ chewing
b. Bleeding on Probing Lack of daily flossing, lack of adequate home Bleedind uring and after probing
care, lack of routine dental appointments
c. Pockets greater than 4mm Lack of adequate home care, lack of dental Pockets greater than 4 mm
knowldege, lack of regualar dental appointments
d Attachment loss greater than 4 mm d. Lack of adequate home care, lack of dental d. Attachment loss greater than 4 mm
e. Xerostomia knowledge, lack of regular dental appointments

8

4. Protection from Health Risks
a. Risk factors - smoking/chewing
e. Lack of adequate home care, lack of dental e. Halitosis
knowledge, lack of knowledge of
smoking/chewing effects on oral cavity
Lack of dental knowledge, lack of overall health Halitosis, hyperkeratosis, bleeding on probing,
knowledge, lack of knowledge of tenacious calculus, deep pocket depths
smoking/chewing and periodontal disease

5. Freedom from Head & Neck Pain

a. Introral Pain/Sensitivity
6. Biologically Sound & Functional Dentition
a. Defective restorations
b. Teeth with signs of disease
c. Missing teeth
d. Other- broken teeth
7. Responsibility for Oral Health
a. Plaque and Calculus Present
b. Substance abuse
8. Conceptualization & Understanding
a. Had questions about DH care/and or oral
disease
Lack of effective home care, lack of daily flossing,
lack fo routine dental apppointments
Lack of regular dental appointments, lack of
dental knowledge, lack of adequate home care,
lack of finances, lack of dental insurance
Lack of dental knowledge, lack of adequate home
care, lack of routine dental appointments, lack of
effective IP plaque removal
c. Lack of routine dental care, lack of finances,
lack of dental knowledge, lack of dental insurance
d. Lack of routine dental care, lack of dental
insurance, lack of finances, lack of dental
knowledge
Lack of effective home care, lack of flossing, lack
of dental appointments, lack of IP cleaning
Lack of dental knowledge, lack of adequate home
care, lakc of knowledge of smoking/chewing on
the oral cavity, lack of overall health, lack of
detanl health education
Lack of dental education, lack of routine dental
appointments
Pain while measuring prbing depths, pain while
scaling during cleanings
#14 has a fracture. #14 amd #15 have broken
distal cusps
Deep probing depths, bleeding during and after
probing, pain while scaling, periodontitis,
gingivitis, #7, #10, & #14 show shadowed areas of
possible decay
c. #30 was extrated due to decay
d. #14 & #15 broken distal cusps
Class IV calculus, moderate on more than half of
the teeth, PHP 2.6 Fair
Pt had questions regarding his dental SRP
treatment needs and prognosis. Pt was curious to
know more about periodontal disease and what he
needed to do to maintain a healthy oral cavity

9
 Jointly Determined Treatment Plan
Date: 10.14.16
Student Name: Hanna Feller
Patient Name: Daniel M.
DOB: 10.03.1980
Patient Goals
Apt #: 1 1. Pt will give consent for tx
Date: 9.6.16 2.
Time Req: 2 hours a. Pt will understand the reasoning
for filling out a health history
b. Pt will answer any questions the
hygienist may have while going over out a health history to the best of
the health history & dental history
3.
a. Pt will understand the reasoning
behind the hygienist taking his vital
signs
b. Pt will consent to getting his vital
signs taken
c. Pt will explain to the hygienist any 3.
abnormal results if they know why
there may be changes/or results that
differ from normal
4)
a. Pt will understand why the
hygienist will be giving him
extra/Intraoral cancer screening
exams
b. Pt will consent to his
extra/intraoral cancer screening
exams
c. Pt will be told if there is an
abnormal lesions/bumps/or
discolorations that are found during
these exams and pt will understand
the results that were found
5.
a. Pt will have a full understanding
10
Educations and Treatment
(Target etiologies)
1. Obtain pt consent forms and place
into pt folder for record keeping
2.
a. Review health history with the pt
and explain the importance of filling
their knowledge
b. Ask any questions that are
unanswered on the health history or
any extra information that needs to
be obtained for the pts chart/health
history/dental history - record in the
pt chart
a. Explain to the pt why it is
important to take their vital signs
before the tx can be done
b. Take pts blood pressure,
temperature, pulse, and respirations -
record in the pt chart
c. Ask the patient to elaborate on any
abnormal results after vital signs are
taken
4.
a. Explain to the patient what the
importance of doing an
intra/extraoral cancer screenings
b. Apply intra/extraoral cancer
screening exams at this time
c. Explain to the pt any abnormal
findings/lesions/bumps/discoloration
s that were found during the exam -
Evaluation
(goal met, partially met or unmet)
1. Pt consented to tx. goal met
2.
a. Pt reviewed health history with
hygienist and understood the
reasonsing for the health history.
Goal met.
b. Pt answered any questions the
hygienist had regarding his
health/dental history. goal met
3.
a. Pt showed an understanding for
the importance of taking vital signs.
goal met.
b. Pt followed directions while vital
signs were being taken. goal met.
c. Pt did not have any abnormal
findings or results and did not have
to elaborate on any findings. Goal
met.
4.
a. Pt showed an understanding of the
importance of intra/extraoral cancer
screening exams. goal met.
b. Pt consented to intra/extraoral
cancer screening exams. goal met.
c. Pt showed understanding that there
were no abnormal findings. goal met.
5.
a. Pt reported that he understood
what CHX rinse is used for. goal met
b. Pt reported that he understood the
CHX directions. goal met.
of what CHX rinse is & why it is
going to be used
b. Pt will consent to using CHX rinse
c. Pt will show an understanding for
how to use CHX rinse
6.
a. Pt will understand what hard
tissue charting is and the importance
of having a hygienist enter this
information into the computer
b. Pt will consent to having hard
tissue charting completed
c. Pt will be informed of his hard
tissue charting by the hygienist and
show understanding
7.
a. Pt will show an understanding of
periodontal probing
b. Pt will consent to periodontal
probing
c. Pt will show that he understands
the results of his peridontal probing
8.
a. Pt will understand what PHP is
and the importance of measuring the
PHP
b. Pt will consent to PHP being
measured
c. Pt will have an understanding for
what his PHP is and the etiology of
plaque
9.
a. Pt will understand what calculus is
b. Pt will be able to demonstrate c-
shaped flossing & bass brushing tq
c. Pt will have an understanding for
brushing 2x daily
10.
11
record in the pt chart
5.
a. Explain to the pt what CHX rinse
is and why it is going to be used for
their tx today
b. Give the pt directions on how to
use CHX rinse & direct them to rinse
in their mouth for approx. 30
seconds, direct them to spit CHX
rinse back into the plastic cup
provided after they are done rinsing
c. Pt will now swish CHX rinse in
their mouth for approx. 30 seconds at
this time & it is recorded in P note in
pt chart
6.
a. Explain to the pt what hard tissue
charting is, and how you are going to
record it on the computer, and why it
is important to do so.
b. Lay pt back in the chair and look
at all teeth in the pts mouth, record
any restorations/current decay into
the computer on the pts chart
c. Let pt know what you are
recording onto their chart as you
record the restorations. If there is
possible decay found wait to let the
DDS tell the pt the dx - document
findings in pt chart
7.
a. Explain to the pt what periodontal
probing is and why we do
periodontal probing during our first
hygiene appts.
b.Perform a full mouth periodontal
probing and record in the pts perio
chart
c. Explain to the pt the probing
c. Pt followed all directions given for
CHX rinse. goal met
6.
a. Pt reported a full understanding of
hard tissue charting, and the
importance of recording this in his
chart on the computer. goal met.
b. Pt consented to hard tissue
charting. goal met.
c. Pt showed an understanding of his
personal hard tissue charting, and
understood the findings that were
reported to him. goal met.
7.
a. Pt showed an understanding for
what periodontal probing is, and the
importance for doing a full mouth
probing. goal met.
b. Pt consented to a full mouth
periodontal probing. goal met.
c. Pt reported that he understood
what probing depths were and how
they were measured. He also
reported the reasons why it is
necessary to do a full mouth
periodontal probing before starting
any tx/cleaning. goal met.
8.
a. Pt showed an understanding for
what PHP is and how it calculates an
overall plaque index. goal met
b. Pt consented to using disclosing
agent. goal met.
c. Pt reported that he understands
what plaque is and where it comes
from. Pt understood the pink and
blue discolorations and what they
stood for. goal met.
9.
a. Pt will understand what their PBI
is, what the purpose is for calculating
a pts PBI
b. Pt will consent to having their PBI
calculated
c. Pt will understand the findings for
their PBI
11.
a. Pt will understand the reasoning
for taking radiographs
b. Pt will consent to having xrays
exposed
c. Pt will follow directions while
radiographs are being exposed
d. pt will understand the findings or
dx of her radiographs
12.
a. Pt will understand the reasoning
for taking before intraoral/extraoral
photos, pt will have an understanding
that he will be having before and
after photos taken
b. Pt will follow directions while the
hygienist takes the before
intraoral/extraoral photos
c. Pt will consent to intra/extraoral
photos
d. Pt will understand the findings in
his intraoral/extraoral before photos
13.
a. Pt will show an understanding for
what subgingival calculus is
b. Pt will show an understanding for
what calculus removal is
c. Pt will understand how deposit
class is decided by the hygienist
14.
a. Pt will show an understanding for
what a caries risk assessment is
12
depths and what the measurements
mean, and the importance of
knowing what the periodontal
readings are before continuing with
any tx
8.
a. Explain to the pt what PHP is and
how it calculates their plauqe index,
and the importance of finding the
PHP
b. Use discolosing agent and apply to
all teeth excluding any: crowns,
bridges, or implants. Rinse the mouth
to reveal the plaque that is on the pts
teeth at this time
c. Explain to the pt what plaque is if
they do not already know and where
plaque comes from. Explain that pink
means that the plaque has been there
for 24 hrs. or less, and that blue
discolorations mean that the plaque
has been on the tooth surface for
more than 24 hrs & record PHP in pt
chart
9.
a. Explain to the pt what calculus is
b. Show the pt how to floss using the
c-shaped tq and how to brushing
using the bass tq & let the pt
demonstrate what they have learned
c. Explain to the pt the importance of
brushing 2x daily - record in pt.
education in pts chart
10.
a. Explain to the pt what PBI is and
how you will be calculating it and
what you will use the information for
when doing the assessment
b. Use the calculator on the computer
a. Pt showed an understanding for
what calculus is. goal met.
b. Pt demonstrated in the proper
manner how to floss using the c-
shape and how to brush using the
bass technique. goal met.
c. Pt reported that he knew the
importance of brushing 2x daily. goal
met.
10.
a. Pt reported that he understood
what PBI was and how it is
calculated using bleeding points
during periodontal probing. goal met.
b. Pt gave consent to calculate PBI.
goal met.
c. Pt showed an understanding for his
results of the PBI calculation. goal
met.
11.
a. Pt reported that he understood the
importance of taking radiographs.
goal met.
b. Pt consented to radiographs being
exposed. goal met.
c. Pt fully understood what to do
during radiographs and agreed to
follow directions. goal met.
d. DDS looked over findings and
they were explained to the pt, the pt
reported that he understood the dx.
goal met.
12.
a. Pt showed an understanding for
what intra/extraoral photos are, and
what they are used for. Pt showed
and understanding for taking before
and after intra/extraoral photos. goal
met.
b. Pt will consent to the caries risk
assessment
c. Pt will show an understanding for
what caries is
d. Pt will show an understanding of
how caries can happen
e. Pt will show an understanding of
how to prevent caries from occurring
f. Pt will be open/honest about his
answers while taking the caries risk
assessment
g. Pt will show an understanding of
the results of his caries risk
assessment
15.
a. Pt will show an understanding for
what local anesthetic is, and why it is
important for them to use local
anesthetic during SRP tx, pt will
have an understanding for his
condition and the possible need for
local anesthetic if cleaning becomes
to painful due to his tooth sensitivity
16.
a. Pt will show an understanding of
what SRP tx is, and why it is being
used for their specific personalized tx
b. Pt will consent to SRP tx
17.
a. Pt will consent to taking after
intra/extraoral photos
b. Pt will show an understanding for
the findings in his after
intra/extraoral photos
18. Pt will understand the prognosis
of his oral condition
19. Pt will show an understanding for
the cost of his tx
20.
13
and figure out the pts PBI calculation
c. Explain the findings of the PBI
calculation & record in pt chart
11.
a. Explain to the pt why taking
radiographs is not only important but
necessary
b. Expose necessary radiographs
c. Explain to the pt what to do during
the radiograph exposure
d. DDS will explain his dx when
he/she looks over the radiographs -
record any current decay or important
findings in pts chart
12. Explain to the pt what the
intra/extraoral photos are used for
and why they are taken, explain that
you are planning to take before and
after photos
b. Give the pt directions for when the
intra/extraoral photos will be taken
c. Take before tx intra/extraoral
photos on the pt
d. Explain to the pt what pictures and
you took and why, show them the
photos and answer any questions they
may have reguarding the
intra/extraoral photographs
13.
a. Explain to the pt what subgingival
calculus is
b. Explain to the pt what calculus
removal is, and why it is important
c. Explain to the pt the caluclus
detection classes and what class they
fall into & record in pt chart
14.
a. Explain to the pt what a caries risk
assessment is
b. Pt understood directions fully for
taking intra/extraoral photos. goal
met.
c. Pt consented to taking
intra/extraoral before photos. goal
met.
d.Pt reported that he understood the
findings in his intra/extraoral before
photos, he also showed an
understanding of why they are
important to take, he had no
questions regarding the before
photos. goal met
13.
a. Pt showed an understanding of
what subgingival calculus. goal met.
b. Pt reported that he understood
what calculus removal. goal met.
c. Pt showed a full understanding for
deposit class detection, and that he
was a cl IV and the reasoning for
that. goal met.
14.
a. Pt showed an understanding of a
caries risk assessment. goal met.
b. Pt consented to the caries risk
assessment. goal met.
c. Pt reported that he fully
understood what caries are. goal met.
d. Pt reported that he understood how
caries can occur. goal met.
e. Pt reported that he understood how
to prevent caries from occuring . goal
met.
15.
a. Pt reported that he understood
what local anesthetic is, and how it is
used, and that it i necessary to use
during his tx plan this time and for
a. Pt will have an understanding for
what happened during the appt. 1 and
also the future appts necessary to
complete tx including: 4 quads of
SRP tx, 6 wk. re-evaluation, and the
importance of 3 month SPM appts.
after SRP is completed
b. Pt will have an understanding for
what will happen during the 2nd
appt.
c. Pt will consent to coming back for
continued tx
21. Pt will show understanding of the
importance of regular dental care
exams
22. Pt will show understanding of the
effects of smoking/chewing on his
oral cavity
14
b. Complete the caries risk
assessment with the pt
c. Explain to the pt what caries are in
a manner that they can understand
d. Explain to the pt how caries can
occur
e. Explain to the pt how he can
prevent caries from occuring to the
best of his ability
f. Ask any extra questions that may
need to be answered for the caries
risk assessment
15.
a. Explain to the pt what local
anesthetic is, and how it is used, and
what it is used for during SRP tx
16.
a. Explain to the pt what SRP tx is
and why it is necessary for their
specific personalized tx.
b. Compete SRP tx on LR quad w/
hand instruments & cavitron then
record in pt chart
17. Explain to the pt his prognosis
and oral condition fully and in a
manner that he can understand
18. Explain to the pt the cost of SRP
tx and the 6 wk. re-evaluation
19.
a. Review with the pt what was
completed during this appt. Explain
to the pt about the tx plan and that it
is going to consist of a total of 5
appts. consisting of: 4 quads of SRP,
a 6 wk. re-evaluation, and 3 mo.
SPM appts. that will be necessary to
keep a healthy mouth & record future
appts. in the P note of your pts chart.
b. Explain what will be completed at
future appointments. goal met.
16.
a. Pt reported that he understood
what SRP tx is, and why it is
necessary for him at this time. goal
met.
b. Pt consented to SRP tx on LR
quad. goal met.
17. Pt reported that he understood his
prognosis and his oral condition
fully. goal met.
18. Pt showed an understanding for
the cost of SRP tx and the 6-wk. re-
evaluation. goal met.
19.
a. Pt understood the review of appt. 1
and what was completed at this appt,
pt understood the entire tx plan and
that it consists of 5 appts, he
understood that he will need to set up
3 mo. SPM appts to keep his mouth
healthy. goal met.
b. Pt had a full understanding of
what will be done in appt. #2. goal
met.
c. Pt scheduled his 2nd appt. w Julie
at the front desk. goal met.
20. Pt showed understanding of the
need for regualr dental appointments
and plans to schedule his 3 mos SPM
appointments at DMACC & see a
dentist for his restorative work that
needs to be done. goal met.
21. Pt did not want to talk about
quitting smoking/chewing at this
time. goal unmet.

Apt #: 2 1. Pt will discuss any changes in his
Date: 9.10.16 health history since his last visit.
Time Req: 1.5 hours 2. Pt will consent to todays treatment
3. Pt will allow vitals to be taken and
understand why while following
directions correctly
4. Pt will agree to use chlorhexadine
rinse and understand the reason for
it.
5. Pt will understand the need for and
extraoral and intraoral exam and
follow directions during
6. Pt will understand the need to
update the hard tissue charting and
cooperate during.
7. Pt will understand the reasoning
for finding a PHP and understand the
findings
8. Pt will understand the benefits and
risk of local anesethic and will
discuss any concerns he has about
using topical and local anesthetic and anesthetic and explain the benefits
be open to using both types of
anesthetic.
9. Pt will follow all directions during
the scaling and root planing and will
express any pain or senstivity
appt 2
c. Walk pt to front desk to schedule
appt 2
20. Give and encourage referral to a
general dentist for regular
appointments and restorative care
21. Discuss with pt the effects of
smoking.chewing on the oral cavity.
Offer pt quitline information
1. Update health history
2. Pt consents to treatment
3. Vital Signs
4. Chlorhexadine rinse
5. Extraoral and Intraoral Exam
6. Hard tissue charting for changes
since last appointment
7. PHP
8. Evaluate the need for local
and risk associated with LA
9. Perform scaling and root planing
15
1. Pt gave consent for tx. goal met.
2. Pt informed the hygienist that
there were no changes to his health
history. goal met.
3.
a. Pt gave consent for vital signs to
be taken. goal met.
b. Pt showed an understanding of his
vital signs and the results for todays
visit. goal met.
4. Pt gave consent for the use of
CHX rinse. goal met.
5. Pt showed understanding of the
importance of the exams and how
they will be conducted. goal met.
6. Pt showed understanding of HTC
and why it is performed and
followed instruction. goal met.
7.
a. Pt gave consent for discolosing
agent to be used to obtain his PHP.
goal met.
b. Pt fully understood his PHP
results. goal met.
8. Pt understood his need for local
anesthetic with the risks and benefits.
goal met.
9. Pt showed an understanding for all
of the directions that were given
 10. Pt will let the hygienist know of
any issues or pain he may have
experieinced during this appt that the
hygiensit may need to know for
future appointments
11. Pt will demonstrate the Bass
brushing technique and c-shape
flossing correctly.
a. Pt wil understand the benefits of
brushing for 2 minutes and also the
benefits of an electric toothbrush
b. Pt will understand the
importance of a good homecare
routine
c. Pt will understand the benefits
of flossing and the different products
that may be used instead of regular
string floss
12. Pt will have scheduled an
appointment with general dentist.
13. Pt will follow and understand all
post-op instructions given to him
14. Pt will understand what his next
visit will consist of and schedule
Appt 3 w Julie at front desk for
contintued SRP tx
15. Pt will show understanding of the
effects of smoking/chewing on his
oral cavity
Apt #: 3 1. Pt will discuss any changes in his
Date: 9.14.16 health history since his last visit.
Time Req: 1.5 hours 2. Pt will consent to todays treatment
3. Pt will allow vitals to be taken and
understand why while following
directions correctly
16
on the LL quad using a cavitron and
hand instruments.
10. Ask pt if he has had any new
discomfort from appointment today
-record in chart for his next visit
11. Pt Education- have pt
demonstrate the Bass brushing
technique and c-shape flossing.
a. discuss increasing brushing
time to 2 minutes. Discuss pt use of
his electric toothbrush
b. evaluate pts current homecare
routine to see if positive changes are
being made.
c. discuss different flossing
options inclusing waterpik and
airflosser.
12. Follow up on appointments made
to the patient's general dentist.
13. Give post-op instructions
14. Explain to pt what will be
completed at appt 3 and walk them to
front desk to schedule next appt
15. Discuss with pt the effects of
smoking.chewing on the oral cavity.
Offer pt quitline information
1. Update health history
2. Pt consents to treatment
3. Vital Signs
during this appt. and followed them
exactly as he was instructed. Pt gave
consent to have SRP tx on LL quad.
goal met.
10. Pt reported that there was no new
discomfort or any comments or
complaints during todays appt. goal
met.
11.
a. Pt demonstrated Bass tq and c-
shaped flossing and reported
undertsanding why flossing is
important for his oral health. goal
met.
b. Pt showed understanding of
brushing for 2 minutes. goal met.
c. Pt showed understanding of the
importance of a good home care
routine. goal met
12. Pt reported that he has not made
an appointment with dentist yet. goal
unmet.
13. Pt reported understanding post-
op instructions. goal met.
14. Pt scheduled appt 3 w Julie at
front desk. goal met.
15. Pt did not want to talk about
quitting smoking/chewing at this
time. goal unmet.
1. Pt gave consent for tx. goal met.
2. Pt informed the hygienist that
there were no changes to his health
history. goal met.
3.
a. Pt gave consent for vital signs to
4. Pt will agree to use chlorhexadine
rinse and understand the reason for
it.
5. Pt will understand the need for and
extraoral and intraoral exam and
follow directions during
6. Pt will understand the need to
update the hard tissue charting and
cooperate during.
7. Pt will understand the reasoning
for finding a PHP and understand the
findings
8. Pt will understand the benefits and
risk of local anesethic and will
discuss any concerns he has about
using topical and local anesthetic and anesthetic and explain the benefits
be open to using both types of
anesthetic.
9. Pt will follow all directions during
the scaling and root planing and will
express any pain or senstivity
10. Pt will let the hygienist know of
any issues or pain he may have
experieinced during this appt that the 10. Ask pt if he has had any new
hygiensit may need to know for
future appointments
11. Pt will demonstrate the Bass
brushing technique and c-shape
flossing correctly.
a. Pt wil understand the benefits of
brushing for 2 minutes and also the
benefits of an electric toothbrush
b. Pt will understand the
importance of a good homecare
routine
c. Pt will understand the benefits being made.
4. Chlorhexadine rinse
5. Extraoral and Intraoral Exam
6. Hard tissue charting for changes
since last appointment
7. PHP
8. Evaluate the need for local
and risk associated with LA
9. Perform scaling and root planing
on the UR quad using a cavitron and
hand instruments.
discomfort from appointment today
-record in chart for his next visit
11. Pt Education- have pt
demonstrate the Bass brushing
technique and c-shape flossing.
a. discuss increasing brushing
time to 2 minutes. Discuss pt use of
his electric toothbrush
b. evaluate pts current homecare
routine to see if positive changes are
17
be taken. goal met.
b. Pt showed an understanding of his
vital signs and the results for todays
visit. goal met.
4. Pt gave consent for the use of
CHX rinse. goal met.
5. Pt showed understanding of the
importance of the exams and how
they will be conducted. goal met.
6. Pt showed understanding of HTC
and why it is performed and
followed instruction. goal met.
7.
a. Pt gave consent for discolosing
agent to be used to obtain his PHP.
goal met.
b. Pt fully understood his PHP
results. goal met.
8. Pt understood his need for local
anesthetic with the risks and benefits.
goal met.
9. Pt showed an understanding for all
of the directions that were given
during this appt. and followed them
exactly as he was instructed. Pt gave
consent to have SRP tx on UR quad.
goal met.
10. Pt reported that there was no new
discomfort or any comments or
complaints during todays appt. goal
met.
11.
a. Pt demonstrated Bass tq and c-
shaped flossing and reported
undertsanding why flossing is
important for his oral health. goal
met.
b. Pt showed understanding of
brushing for 2 minutes. goal met.
 of flossing and the different products
that may be used instead of regular
string floss
12. Pt will have scheduled an
appointment with general dentist.
13. Pt will follow and understand all
post-op instructions given to him
14. Pt will understand what his next
visit will consist of and schedule
Appt 4 w Julie at front desk for
contintued SRP tx
15. Pt will show understanding of the
effects of smoking/chewing on his
oral cavity
Apt #: 4 1. Pt will discuss any changes in his
Date: 9.18.16 health history since his last visit.
Time Req: 1.5 hours 2. Pt will consent to todays treatment
3. Pt will allow vitals to be taken and
understand why while following
directions correctly
4. Pt will agree to use chlorhexadine
rinse and understand the reason for
it.
5. Pt will understand the need for and
extraoral and intraoral exam and
follow directions during
6. Pt will understand the need to
update the hard tissue charting and
cooperate during.
7. Pt will understand the reasoning
for finding a PHP and understand the
findings
8. Pt will understand the benefits and
c. discuss different flossing
options inclusing waterpik and
airflosser.
12. Follow up on appointments made
to the patient's general dentist.
13. Give post-op instructions
14. Explain to pt what will be
completed at appt 4 and walk them to
front desk to schedule appt 4
15. Discuss with pt the effects of
smoking.chewing on the oral cavity.
Offer pt quitline information
1. Update health history
2. Pt consents to treatment
3. Vital Signs
4. Chlorhexadine rinse
5. Extraoral and Intraoral Exam
6. Hard tissue charting for changes
since last appointment
7. PHP
18
c. Pt showed understanding of the
importance of a good home care
routine. goal met
12. Pt reported that he has not made
an appointment with dentist yet. goal
unmet.
13. Pt reported understanding post-
op instructions. goal met.
14. Pt scheduled appt 4 w Julie at
front desk. goal met.
15. Pt did not want to talk about
quitting smoking/chewing at this
time. goal unmet.
1. Pt gave consent for tx. goal met.
2. Pt informed the hygienist that
there were no changes to his health
history. goal met.
3.
a. Pt gave consent for vital signs to
be taken. goal met.
b. Pt showed an understanding of his
vital signs and the results for todays
visit. goal met.
4. Pt gave consent for the use of
CHX rinse. goal met.
5. Pt showed understanding of the
importance of the exams and how
they will be conducted. goal met.
6. Pt showed understanding of HTC
and why it is performed and
followed instruction. goal met.
7.
a. Pt gave consent for discolosing
agent to be used to obtain his PHP.
risk of local anesethic and will
discuss any concerns he has about
using topical and local anesthetic and
be open to using both types of
anesthetic.
9. Pt will follow all directions during
the scaling and root planing and will
express any pain or senstivity
10. Pt will let the hygienist know of
any issues or pain he may have
experieinced during this appt that the
hygiensit may need to know for
future appointments
11. Pt will demonstrate the Bass
brushing technique and c-shape
flossing correctly.
a. Pt wil understand the benefits of
brushing for 2 minutes and also the
benefits of an electric toothbrush
b. Pt will understand the
importance of a good homecare
routine
c. Pt will understand the benefits
of flossing and the different products
that may be used instead of regular
string floss
12. Pt will have scheduled an
appointment with general dentist.
13. Pt will follow and understand all
post-op instructions given to him
14. Pt will understand what his next
visit will consist of and schedule
Appt 5 w Julie at front desk for
conintued SRP tx
15. Pt will show understanding of the
effects of smoking/chewing on his
oral cavity
19
8. Evaluate the need for local
anesthetic and explain the benefits
and risk associated with LA
9. Perform scaling and root planing
on the UL quad using a cavitron and
hand instruments.
10. Ask pt if he has had any new
discomfort from appointment today
-record in chart for his next visit
11. Pt Education- have pt
demonstrate the Bass brushing
technique and c-shape flossing.
a. discuss increasing brushing
time to 2 minutes. Discuss pt use of
his electric toothbrush
b. evaluate pts current homecare
routine to see if positive changes are
being made.
c. discuss different flossing
options inclusing waterpik and
airflosser.
12. Follow up on appointments made
to the patient's general dentist.
13. Give post-op instructions
14. Explain to pt what will be
completed at appt 5 and walk them to
front desk to schedule next appt
15. Discuss with pt the effects of
smoking.chewing on the oral cavity.
Offer pt quitline information
goal met.
b. Pt fully understood his PHP
results. goal met.
8. Pt understood his need for local
anesthetic with the risks and benefits.
goal met.
9. Pt showed an understanding for all
of the directions that were given
during this appt. and followed them
exactly as he was instructed. Pt gave
consent to have SRP tx on UL quad.
goal met.
10. Pt reported that there was no new
discomfort or any comments or
complaints during todays appt. goal
met.
11.
a. Pt demonstrated Bass tq and c-
shaped flossing and reported
undertsanding why flossing is
important for his oral health. goal
met.
b. Pt showed understanding of
brushing for 2 minutes. goal met.
c. Pt showed understanding of the
importance of a good home care
routine. goal met
12. Pt reported that he has not made
an appointment with dentist yet. goal
unmet.
13. Pt reported understanding post-
op instructions. goal met.
14. Pt scheduled appt 5 w Julie at
front desk. goal met.
15. Pt did not want to talk about
quitting smoking/chewing at this
time. goal unmet.
Apt #: 5 1. Pt will discuss any changes to his
Date: 11.06.16 health history since last visit
Time Req: 1 hour 2. Pt will give consent to treatment
3. Pt will allow vital signs to be
taken
4. Pt will consent to use CHX rinse.
5.
a. Pt will understand the need for a
reassesment and will give his
consent- including a fm probing to
check probing depths after tx
b. Pt will have an understanding for
the findings during the reassessment
and fm probing
6. Pt will show understanding of the
before and after intra/extraoral
photos that were taken at previous
appts. and any findings that were
found in the photos.
7.
a. Pt will show understanding of the
progression of his tx, and what the
healing process consists of, the pt
will show understanding of the need
for a 3 month SPM and commit to
returning for these appointments in
the future
b. Pt will reveal that he has been
brushing with electric toothbrush
using the bass & vertical tq and
flossing using the c-shaped flossing
tq
8. Pt will consent to any
supragingival scaling that might need
ot be done at this appt.
9.
20
1. Update pt health history
2. Obtain consesnt for treatment
3. Vital signs
4. CHX rinse
5.
a. Explain to the pt why it is
important to reassess all of the
tissues, probing depths, and teeth
since his last visit
b. Explain to the pt all of the findings
during the reassessment and fm
probing so that he will understand
fully
6. Show the pt before and after
intra/extraoral photos and explain
any findings so he can understand his
condition
7.
a. Explain to the pt his progession,
and the healing process and what it
consists of. Explain to the pt the
importance of maintaining a 3 mo.
SPM and ask him to return for these
future appts.
b. Discuss with him about using the
bass & vertical brushing tqs, and
flossing using the c-shaped flossing
tq. Demonstrate each of these tqs for
the pt, and give him a chance to show
you what he has learned
8. Complete any supragingival
scaling that needs to be done today
9.
a. Explain to the pt what polishing is
in a manner that he can understand
b. Explain to the pt what polishing is
1. Pt gave consent for tx. goal met.
2. Pt reported to have no changes to
his health history since last visit. goal
met.
3.Pt gave consesnt to take vitals. goal
met
4. Pt gave consent for CHX rinse
use. goal met.
5.
a. Pt reported an understanding for
reassessment and fm probing and the
reason why it was important to do so.
goal met.
b. Pt had a full understanding of his
findings during the reassessment and
fm probing. goal met
6. Pt reported that he understood his
intra/extraoral photo findings. goal
met
7.
a. Pt showed an understanding for his
condition, the progression, and the
healing process, he also reported that
he understood the importance of
maintaining 3 mo. SPM appts
following todays tx. goal met.
b. Pt correctly demonstrated the bass
brushing tq, vertical brushing tq, and
c-shaped flossing tq. goal met.
8. Pt gave consent for supragingival
scaling. goal met
9.
a. Pt showed an understanding of
polishing. goal met
b. Pt reported that he understood the
benefit of polishing and what it is
 a. Pt will consent to polishing all
surfaces of all teeth
b. Pt will show an understanding for
what polishing is used for
10. Pt will consent to flossing
11.
a. Pt will consent to the use of
fluroide varnish
b. Have and understanding for how it
helps to rebuild enamel.
12. Pt will consent to receiving a
goody bag with dental supplies at the
end of the appt.
13.
a. Pt will have an understanding of
what an SPM appt is, and why it is
necessary for his specific oral health
condition
b. Pt will schedule his first 3 mo.
SPM appt w/Julie at the front desk
14. Pt will have scheduled an
appointment with dentist
15. Pt will show understanding of the
effects of smoking/chewing on his
oral cavity
Apt #: 6 1. Pt will discuss any changes in his
Date: 02.10.17 health history since his last visit.
Time Req: 1 hour 2. Pt will consent to todays treatment
3. Pt will allow vitals to be taken and
understand why while following
directions correctly
4. Pt will agree to use chlorhexadine
21
used for and what the benefit is
10. floss all contacts between all
teeth in the mouth
11.
a. Spread fluoride varnish on all tooth
reachable tooth surfaces using small
brush provided in the fluoride varnish
package
b. Explain to the pt what the benefit
of fluoride varnish is and the
reasoning for using it
12. Pack up a goody bag with any
dental essentials necessary for the pts
homecare
13.
a. Explain to the pt what SPM appts
are and how it will benefit his
specific oral condition and that it is
necessary for future tx to keep his
oral cavity healthy
b. Walk pt up to the front desk and
ask them to schedule their first 3 mo.
SPM appt. w Julie
14. Follow-up on appointments made
with dentist for restorative work
15. Discuss with pt the effects of
smoking.chewing on the oral cavity.
Offer pt quitline information
1.Pt will update health history
2. Pt will consent to tx
3.Vital signs
4.CHX rinse
5. . Extraoral and Intraoral Exam
6. Hard tissue charting for changes
since last appointment
used for. goal met.
10. Pt gave consent to have his teeth
flossed by the hygienist. goal met
11.
a. Pt gave consent for fluoride
varnish. goal met
b. Pt reported that he understood the
benefits of fluoride varnish and that
it helped to rebuild and strengthen
enamel. goal met
11. Pt gave consent to take home a
goody bag with dental essentails for
homecare. goal met
13.
a. Pt had a full understanding of what
3 mo. SPM appts are and how they
would benefit his specific oral
condition and that it is necessary for
his oral health in the future. goal met
b. Pt scheduled his first 3 mo. SPM
appt w Julie at the front desk. goal
met
14. Pt states he had made an
appointment with dentist to start
treatment on existing failed
restorations. goal met.
15. Pt did not want to talk about
quitting smoking/chewing at this
time. goal unmet.
1. Pt gave consent for tx. goal met.
2. Pt informed the hygienist that
there were no changes to his health
history. goal met.
3.
a. Pt gave consent for vital signs to
be taken. goal met.
rinse and understand the reason for
it.
5. Pt will understand the need for and
extraoral and intraoral exam and
follow directions during
6. Pt will understand the need to
update the hard tissue charting and
cooperate during.
7. Pt will understand the reasoning
for finding a PHP and understand the
findings
8. Pt will follow all directions during
the full mouth debridement and will
express any pain or senstivity
9. Pt will let the hygienist know of
any issues or pain he may have
experieinced during this appt that the
hygiensit may need to know for
future appointments
10. Pt will demonstrate the Bass
brushing technique and c-shape
flossing correctly.
a. Pt will understand the benefits of
brushing for 2 minutes and also the
benefits of an electric toothbrush
b. Pt will understand the
importance of a good homecare
routine
c. Pt will understand the benefits
of flossing and the different products
that may be used instead of regular
string floss
11. Pt will follow all directions
during polishing and post op
instructions for flouride varnish
12. Pt will understand what his next
visit will consist of and schedule his
second SPM appt w Julie at front
22
7. PHP
8. Perform a full mouth debridement
on the entire mouth using hand
instruments.
9. Ask pt if he has had any new
discomfort from appointment today
-record in chart for his next visit
10. Pt Education- have pt
demonstrate the Bass brushing
technique and c-shape flossing.
a. discuss increasing brushing
time to 2 minutes. Discuss pt use of
his electric toothbrush
b. evaluate pts current homecare
routine to see if positive changes are
being made.
c. discuss different flossing
options inclusing waterpik and
airflosser.
11. Perform polishing with hand
piece and apply fluoride varnish
12. Explain to pt what will be
completed at next SPM appt and
walk them to front desk to schedule
next appt
13. Discuss with pt the effects of
smoking.chewing on the oral cavity.
Offer pt quitline information
b. Pt showed an understanding of his
vital signs and the results for todays
visit. goal met.
4. Pt gave consent for the use of
CHX rinse. goal met.
5. Pt showed understanding of the
importance of the exams and how
they will be conducted. goal met.
6. Pt showed understanding of HTC
and why it is performed and
followed instruction. goal met.
7.
a. Pt gave consent for discolosing
agent to be used to obtain his PHP.
goal met.
b. Pt fully understood his PHP
results. goal met.
8. Pt showed an understanding for all
of the directions that were given
during this appt. and followed them
exactly as he was instructed. goal
met.
9. Pt reported that there was no new
discomfort or any comments or
complaints during todays appt. goal
met.
10.
a. Pt demonstrated Bass tq and c-
shaped flossing and reported
undertsanding why flossing is
important for his oral health. goal
met.
b. Pt showed understanding of
brushing for 2 minutes. goal met.
c. Pt showed understanding of the
importance of a good home care
routine. goal met
11. Pt reported understanding post-
op instructions. goal met.
 desk 12. Pt scheduled appt 3 w Julie at
13. Pt will show understanding of the front desk. goal met.
effects of smoking/chewing on his 13. Pt did not want to talk about
oral cavity quitting smoking/chewing at this
time. goal unmet.

Apt #:
Date:
Time Req:
Apt #:
Date:
Time Req:

23