Vous êtes sur la page 1sur 24

Date: 10/14/16 DMACC

Student Name: Emily Hummel Dental Hygiene


Patient Name: Donella T
DOB: N/A Treatment Plan
Medical History & Medications: ASA Physical Status Dental History: Occlusion:
Patient is taking Simvastatin for high Classification: Patient said she recently went to her Class I
cholesterol. Ranitidine for acid reflux. Class I dentist 1 week ago and was told that she
Naproxen bid for arthiritis pain. Aspirin needed a "deep cleaning" on all four
every morning and a sleep aid when quadrants. The patients dentist told her
needed. that she needs a root canal on her lower
molar #18. He suggested the deep
cleaning be completed before the root
canal. Due to the price of SRP treatment
in a dental office she decided to come
back to DMACC Dental Hygiene Clinic
to complete SRP. Patient has multiple
extracted teeth #1, 2, 3, 4, 5, 12, 13, 14,
16, 17, 19, 31, and 32. Patient also has
multiple restorations, #9 IDLF
composite, #11 DLF composite, #18,
21, and 28 O amalgam, #5 and 29 OD
amalgam, # 20 OD composite, and # 9
and 10 MIF composite.
Developmental Abnormalities & Defects: Restorative Problems: Other: Radiographic Evidence:
Popping in left TMJ, bilateral mandibular #18 is in need of a root canal No
tori, attrition on # 27-22, wear faucets on 6
and 11

Risk Factors are as follows (be specific).


1. Systemic Health: 3. Caries High risk
CVD: No Sugar Intake: Intermediate
Diabetes Mellitus: No Streptococcus Mutans Count: High
Respiratory Disease: No Plaque-Removal Ability: Poor. Patient does not have
dexterity limitations and is able to
use a toothbrush and floss
normally. The patient does not
spend enough time removing
plaque from her teeth
1
Osteoporosis: None Socioeconomic Status: Middle Class
Preterm Low Birth Weight: No Plaque Retentive Factors: Crown margins, decay
concavities, deep pockets,
missing teeth
Behavioral Status: Patient is interested in Fluoride History: Patient drinks flouridated water
returning for 3 month SPM regularly both as a child and
appointments to keep her currently. Patient uses flouride
remaining teeth intact. toothpaste daily.
Psychosocial Status: Normal Past & Present Caries Activity: Patient has Class V decay on
facials of 6 and 28. Class IV
decay on #10. Class II decay in
two areas on #18.Patient also has
multiple restorations, #9 IDLF
composite, #11 DLF composite,
#18, 21, and 28 O amalgam, #5
and 29 OD amalgam, # 20 OD
composite, and # 9 and 10 MIF
composite.
Medication Considerations: None Other: N/A
Other: None
4. Periodontal Disease: Generalized moderate
2. Oral & Pharyngeal Cancer: No (host environmental risk factors/indicators)
Tobacco Use: Cigarette Previous History of Disease: Patient has gone through SRP in
the past, and did not maintain
SPM appointments or proper oral
care.
Race: Caucasian Classification of Disease(s): Generalized moderate
periodontits
Alcohol Use Average Clinical Attachment Loss: Generalized slight/moderate
Sun Exposure: She takes smoke breaks Stress Factors
outside at work. After work
patient regularly takes a walk
around her neighborhood for
excercise.
Pathology: None PHP: 2 fair
Other: N/A PBI: 22% slight
Deposits Classification: Class V
Bacterial Pathogens: Decay causing pathogens are high

2
in this patients oral cavity. Patient
scored a 8717 on the caries
suseptability test.
Tobacco Use: Cigarettes
Glycemic Control None
Inherited Risk None
Other: None

3
Date: 10/14/16
Student Name: Emily Hummel
Patient Name: Donella T
DOB: N/A

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:

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: Tobacco Use

4
5
Date: 10/14/16
Student Name: Emily Hummel
Patient Name: Donella T
DOB: N/A

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


Patient is a 62 year old female seeking regular dental cleanings to maintain remaining teeth. She has not been into the DMACC Dental Clinic to get
her teeth cleaned in 3 years. She was last seen at the DMACC Dental Clinic in 2013. Patient has pain in lower left molar and her doctor at the Dental
Plaza recommended she have a root canal on that tooth. Her doctor recommended she got a "deep cleaning' before the root canal. She would also
like to get back on a regular cleaning schedule. My patient reports she smokes cigarettes but is somewhat interested in quitting. She reports that her
partner also smokes which makes it hard for her to quit. She would also like her teeth to be whiter and hoped that this cleaning plus whitening
toothpaste would help whiten her teeth. She brushes one to two times a day and trys to floss every day. The patient reports severe dental anxiety and
insists on nitrous for her scaling appointments. She also reports sensitivity under her gums and on her teeth.

2. Hypotheses (differential diagnosis):


Bleeding on probing
Periodontitis
Gingivitis
Sensitivity/gingival pain
Staining
Attrition
Halitosis
Calculus
Decay concavities causing plaque retention
Fair PHP due to: inadequate plaque removal
Limited finances

3. Inquiry Strategy:
Review health history
Review dental history
Extra-oral and intra-oral exams
Hard tissue charting and exam
CHX rinse before treatment
Full mouth periodontal assesment
PHP
PBI
Deposit classification
Caries risk assesment
Nutritional counseling
6
Intra-oral and extra-oral photos
4 quads SRP with anesthetic and nitrous
extensive patient education regarding gingivitis, periodontitis, and homecare.
demonstrate proper brushing and flossing technique.
Referral back to dentist for restorative dental treatment
6 week re-evaluation
3 month SPM
Prescription for CHX rinse

7
Date: 10/14/16
Student Name: Emily Hummel
Patient Name: Donella T.
DOB: N/A

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 a) moderate plaque accumulation
lack of adequate home care heavy calculus
lack of dental knowledge missing teeth
b) Gingiva lack of adequate home care b) gingiva are are bolbous and bled easily during
lack of dental knowledge probing
c) Breath lack of brushing tongue c) halitosis
lack of tobacco knowledge
2) Freedom From Anxiety and Stress
a) Anxiety about proximity of clinician lack of past positive dental experiences a)patient does not want to be in any pain because
confidentiality or previous dental experience lack of previous dental care she had a bad experience in the past. She
lack of dental knowledge requested anestethetic and nitrous for all
treatment.
b) Oral habits lack of correct brushing form b) patient does not take enough time brushing and
lack of correct flossing technique does not use proper technique. Patient does not
floss often enough but when she does she does not
do it effectively.
3) Skin & Mucous Membrane Integrity of Head
and Neck
a) Gingival inflammation lack of adequate home care gingiva are erythematous and edematous, bleeding
lack of routine dental care on probing
inefficient interproximal home care and
toothbrushing technique
lack of dental knowledge
b) Bleeding on probing lack of adequate home care bleeding during and after probing
lack of routine dental care
inefficient interproximal home care and
toothbrushing technique
lack of dental knowledge
c) Pockets greater than 4mm lack of adequate home care pockets greater than 4 mm

8
lack of dental knowledge
lack of regular dental care
d) Attachment loss greater than 4mm lack of adequate home care attachment loss greater than 4 mm
lack of dental knowledge
lack of regular dental care
4) Protection from Health Risks
a)Other (Tobacco Use) lack of knowledge about tobacco use patient smokes tobacco and wants to quit but feels
lack of dental knowledge as though it's too hard since her partner is a
smoker as well
5) Freedom from Head and Neck Pain
a) Extra-/Intra- oral pain or sensitivity lack of adequate home care pain in gingiva upon light probing
lack of routine dental care pain in gingiva upon light calculus detection
lack of dental knowledge
6) Biologically Sound & Functional Dentition
a) Teeth with signs of disease lack of adequate home care Patient has Class V decay on facials of 6 and 28.
lack of routine dental care Class IV decay on #10. Class II decay in two areas
lack of dental knowledge on #18. 6 mm probing depths.
b) Rampant caries lack of adequate home care 5 areas of decay charted.Patient has Class V decay
lack of routine dental care on facials of 6 and 28. Class IV decay on #10.
lack of dental knowledge Class II decay in two areas on #18
lack of dental insurance
c) Missing teeth lack of dental care missing # 1, 2, 3, 4, 5, 12, 13, 14, 16, 17, 19, 31,
lack of finances and 32.
lack of dental insurance
lack of dental knowledge
7) Responsibility for Oral Health
a) Plaque and Calculus Present lack of adequate home care Class V calculus; PHP 2 Fair
lack our routine dental care
lack of dental knowledge
lack of knowledge of etiology of plaque and
calculus
8) Conceptualization & Understanding
a) Has questions about gental hygiene care and lack of routine dental care Patient has question regarding her treatment needs
or oral disease lack of dental education and prognosis

9
Jointly Determined Treatment Plan
Date: 10/14/16
Student Name: Emily Hummel
Patient Name: Donella T
DOB: N/A
Patient Goals Educations and Treatment Evaluation
(Target etiologies) (goal met, partially met or unmet)
Apt #: 1 1) patient will give consent for 1) Obtain patient consent for 1) patient consented to treatment.
Date: 6/23/16 treatment. treatment and record in patient chart goal met
Time Req: 1 hours
2) 2) Review health history 2)
a) patient will show a) explain to patient the a) patient showed understanding
understanding of how her health can importance of having a completed of why a health history is important
affect treatment and why having a health and dental history and how it and how it can affect treatment. goal
complete health history is important may affect treatment met
b) patient will answer all b) clarify any questions about or b) patient clarified all questions
questions asked about and any issues discrepancies in the history with the about the health history. goal met
found in the health history. patient. c) patient revealed all health
c) patient will reveal all dental c) discuss dental history with concerns and dental history. goal met
history and dental concerns patient and determine current dental
status. Record in patient chart/note
3) 3)
a) patient will consent to vitals 3) Vital signs a) patient showed understanding
being taken a) explain to patient why taking of vital signs and why they are taken.
b) patient will show vital signs is necessary and how they goal met
understanding as to why her vital will be taken. b) patient consented to taking
signs need to be taken and the b) take blood pressure, pulse, and vital signs. goal met
equipment used to take them. consent respirations and record in patient c) patient showed understanding
to having vital signs taken. chart. of findings and clarified any
c) patient will show c) report findings to patient and abnormal readings. goal met
understanding of what her vital sign discuss any abnormalities or
readings mean and explain if they are concerns with the patient. Have
normal for her. patient clarify any findings.
4)
4) 4) Chlorhexidine Pre-Rinse a) patient showed understanding
a) patient will show a) Give patient instructions on of how to use the chlorhexadinse
understanding of instructions for the how to rinse and how long they need rinse. goal met
use of chlorhexadine rinse. to rinse for. b) patient showed understanding
b) patient will show b) explain to patient why it is of what chlorhexadine is. goal met
10
understanding of why chlorhexadine important that she rinses with c) patient consented to using
rinse is used chlorhexadine chlorhexadine rinse. goal met
c) patient will consent to use of c) administer chlorhexadine rinse
chlorhexadine rinse and then use the and record in patient chart.
rinse 5)
5) Extra-Oral/ Intra-Oral Exam a) patient showed understanding
5) a) explain to the patient what an of importance of extraoral and
a) patient will understand the extraoral and intraoral exam consist intraoral exams and how it will be
importance of an extraoral and of and why it is important to her done. goal met
intraoral exam and how it will be treatment and health. b) patient consented to extraoral
conducted. b) perform extraoral and intraoral and intraoral exam. goal met
b) patient will consent to having exam then record findings in the c) patient clarified findings and
an extraoral and intraoral exam patient chart. showed understanding of findings.
completed c) report and explain any findings goal met
c) patient will show with the patient.
understanding of anything that is
found and will explain if needed.
6) Hard Tissue Charting 6)
6) a) explain to patient what hard a) patient showed understanding
a) patient will understand what a tissue charting is and why it needs to of HTC and why it is done. goal met
hard tissue dental chart is and why it be performed. b) patient followed all instruction.
necessary to have completed b) perform hard tissue charting goal met
b) patient will fully cooperate and record in patient chart. c) patient clarified and showed
during the recording of the hard c) discuss and clarify any findings understanding of findings. goal met
tissue chart with patient.
c) patient will show 7)
understanding of and clarify any 7) a) patient showed understanding of
findings. a) explain to patient the Oraqix Oraqix procedure. goal met
procedure b) patient showed understanding of
7) b) explain to patient the benefits of benefits of Oraqix. goal met
a) patient will show understanding Oraqix and express their c) patient asked questions and
of the procedure of Oraqix understanding concerns she had. goal met.
b) patient will understand benefits c) address and answer any d) patient consented to treatment.
of Oraqix questions or concerns patient has goal met.
c) patient will discuss any d) obtain consent for Oraqix e) patient followed all directions
concerns she has about using Oraqix. application and record it in the and expressed discomfort when felt.
d) patient will consent to Oraqix patients chart goal met
e) patient will follow all directions e) encourage the patient to keep
during Oraqix and express any calm reassuring them throughout the
11
discomfort appointment 8)
a) patient showed understanding
of periodontal probing. goal met
8) 8) Full Mouth Periodontal Probing b) patient followed all directions.
a) patient will show a) educate patient as to what goal met
understanding the procedure and periodontal probing is, why it is c) patient showed understanding
reasonding of periodontal probing done, and how it will be done of findings. goal met.
b) patient will follow directions b) perform full mouth periodontal d) patient showed understanding
during the full mouth probing probing. of the etiology of gingivitis and
c) patient will show c) report and discuss findings with periodontal disease. goal met.
understanding of the findings patient including PBI and periodontal
explained to her classifications.
d) patient will show d) discuss etiology of gingivitis 9)
understanding of the etiology of and periodontal disease. a) patient showed understanding
gingivitis and periodontal disease. of PHP and how it will be measured.
9)PHP goal met
9) a) explain to patient what PHP is b) patient followed all directions.
a) patient wil show understanding and how it will be assessed. goal met
of PHP and how it will be measured. b) calculate PHP c) patient showed understanding
b) patient will follow directions c) report and discuss findings with of etiology of plaque. goal met.
during PHP. patient and record in patient chart.
c) patient will show d) discuss etiology of plaque.
understanding of findings.
d) patient will show understanding 10) patient demonstrated brushing
of the etiology of plaque and its and flossing technique. goal met
afffect on the teeth
10) Have patient demonstrate current
10) patient will demonstrate brushing brushing and flossing technique. 11) patient showed understanding of
and flossing technique. the Bass technique. goal met.
11) Demonstrate Bass technique
11) a) discuss the reasoning behind
a) patient will show this technique and clarify any 12)
understanding of the Bass brushing questions the patient has. a) patient showed understanding
technique. of c-wrap flossing. goal met.
12) Demonstrate c-wrap flossing
12) techinique
a) patient will understand how c- a) discuss the reasoning behind 13)
wrap flossing is done. using this technique and clarify any a) patient showed understanding
questions the patient has. of etiology of calculus and why it
12
should be removed. goal met
13) 13) Deposit Recognition b) patient tolerated procedure
a) patient will show a) discuss etiology of calculus and well. goal met
understandings of etiology of purpose of performing deposit c) patient showed understanding
calculus and why it needs to be recognition. of findings.
removed. b) perform deposit recognition.
b) patient will tolerate calculus c) report findings to patient and 14)
detection well. record in patient chart. a) patient showed understanding of
c) patient will understand findings why radiographs are important and
and the significance 14) X-rays necessary. goal met
a) explaining to the patient why b) pt has not contacted Dental
14) radiographs are important and Plaza to have current x-rays sent to
a) pt will understand the reasoning necessary DMACC Clinic. goal unmet
for radiographs b) explained to the patient the c) X-rays not present yet. goal
b) pt will contact Dental Plaza and importance of having current X-rays unmet
have current X-rays sent to DMACC on file.
Clinic. c) explained the findins and
c) pt will understand the findings diagnosis of her radiographs 15)
or diagnosis of her radiographs a) patient showed understanding
of why a complete exam is needed.
15) Full Mouth Examination goal met
15) a) explain why an exam by the b) patient agreed to complete
a) pt will show understanding of dentist is necessary and what the exam.
why a complete dental exam is dentist will do during the exam. c) patient showed understanding
necessary. b) have the dentist perform exam. of exam findings. goal met
b) patient will agree to complete c) discuss and clarify any findings
exam. from radiographic exam and oral
c) patient will show exam done by the dentist with the 16)
understanding of exam findings and patient. a) patient showed understanding
ask any questions she has. d) determine need for prescription of the need for photos. goal met
toothpaste and/or CHX rinse b) patient followed directions. goal
16) met
a) pt will show understanding of 16) Intra-Oral/Extra-Oral Photos c) patient showed understanding of
the reason for taking photos. a) explain to patient the reason for findings. goal met
b) patient will follow directions taking photos.
while taking photos. b) take photos. 17)
c) patient will show c) show photos and discuss any a) patient showed understanding
understanding of findings. findings with the patient. of recommended treatment,
evaluation, and 3 month recall. goal
13
17) Determine treatment plan. met
17) a) discuss with patient that
a)patient will show understanding periodontal scaling and root planing
of recommended treatment, with local anesthetic will be needed
evaluation, and 3 month recall. and that we will be able to complete 18) patient showed understanding of
1 quadrant at the next two her prognosis with/without treatment.
appointments and the whole upper goal met
arch at the third appointment. Each
18) patient will understand the will be one hour appointments.
prognosis of her oral condition Discuss that a six week evaluation
with/without treatment. following treatment is recommended
and that we recommend a 3 month 19)
19) recall. a)patient showed understanding of
a) patient will show tobacco use and its effects on the oral
understanding of tobacco use and its 18) Prognosis cavity
effects on the oral cavity. a) discuss prognosis of patient's b) patient understood the benefits
b) patient will understand the oral condition following treatment/no of smoking cessation and agreed to
benefits of smoking cessation and treatment. access quitline
access quitline c) patient agreed to discuss more
c) patient will agree to discuss 19) in the future
more in the future a) discuss with patient tobacco use
and its effects on the oral cavity 20) patient showed understanding of
20) b) discuss with patient benefits of the cost of treatment. goal met
a) patient will show smoking cessation and accessing
understanding of the cost of quitline
treatment. c) discussed with patient future 21) patient showed understanding of
discussion about tobacco cessation how many appointments would be
21) patient will agree to attend all the needed and how long each
required appointments and show 20) Cost appointment would be. goal met.
understanding of how many and how a) discuss estimated cost of
long her appointments will be. treatment with patient. 22)
a) patient showed understanding
22) 21) Discuss number of appointments of the need for regular dental visits
a) patient will show and length of appointments and agreed to set an appointment
understanding of the importance of with her dentist. goal met.
regular dental care and examinations 22) Referrals b) patient will schedule an
by her dentist. a) give and discuss referral to appointment with her dentist once
b)pt will schedule an appointment patients general dentist for regularly her appointments at the DMACC
with her dentist. intervalled examinations and Clinic are completed. Goal unmet
14
restorative care
b)encourage patient to schedule
an appointment with her dentist.

Apt #: 2 1) Patient will discuss any changes in 1) Update health history 1) Patient revealed changes in her
Date: 6/30/16 her health history since her last visit. health history. goal met
Time Req: 1 hour 2) Patient will consent to todays
treatment 2) Patient consents to treatment 2) Patient consented to todays
3) Patient will allow vitals to be treatment. goal met
taken and understand why while 3) Vital Signs
following directions correctly 3) Patient allowed vitals to be taken.
4) Patient will agree to use goal met
chlorhexadine rinse and understand 4) Chlorhexadine rinse
the reason for it. 4) Patient consented to chlorhexadine
rinse. goal met
5) Patient will understand the need
for and extraoral and intraoral exam 5)Extraoral and Intraoral Exam 5) Assesment completed . goal met.
and follow directions during
6) Patient will understand the need to 6) Changes in hard tissue charting
update the hard tissue charting and 6)Hard tissue charting for changes completed. goal met
cooperate during. since last appointment
7) Completed patients PHP and
7)Patient will understand the patient understood findings. goal
reasoning for finding a PHP and 7) PHP met.
understand the findings
8) Perform nitrous sedation on 8) Patient understood the benefits
8) Patient will understand the patient. and risks of Nitrous and asked any
benefits and risks of Nitrous Oxide questions she had. goal met
and will discuss any concerns she 9) Evaluate the need for local
has. anesthetic and explain the benefits 9)Patient understands the risk and
and risk associated with LA benefits of LA. goal met
9)Patient will understand the benefits
and risk of local anesethic and will 10) Perform scaling and root planing
discuss any concerns she has about on the LL quad using a cavitron and 10)Patient followed all directions
using topical and local anesthetic and hand instruments. during scaling and root planing and
be open to using both types of expressed pain. goal met
anesthetic. 11) Patient Education, Have patient
demonstrate the Bass brushing 11)patient demonstrated the Bass
10) Patient will follow all directions technique and c-shape flossing. technique and c-shape flossing. goal
15
during the scaling and root planing a) discuss increasing brushing met.
and will express any pain or time to 2 minutes. Discuss options of a)Patient showed understanding
senstivity an electric toothbrush of the benefits of brushing for 2min.
b) evaluate patients current goal met
11) Patient will demonstrate the Bass homecare routine to see if positive b)Patient understands the
brushing technique and c-shape changes are being made. importance of a good homecare
flossing correctly. c) discuss different flossing routine. goal met
a) Patient wil understand the options inclusing waterpik and c)Patient understand the benefits of
benefits of brushing for 2 minutes airflosser. flossing and the different products
and also the benefits of an electric available.goal met
toothbrush 12) follow up on appointments made
b)Patient will understand the to the patient's general dentist. 12) Patient has not made follow up
importance of a good homecare appointments with his dentist. goal
routine 13) Give post-op instructions unmet.
c) Patient will understand the
benefits of flossing and the different 13) Patient followed and understood
products that may be used instead of all post-op instructions. goal met
regular string floss

12) Patient will have scheduled an


appointment with her dentist.

13) Patient will follow and


understand all post-op instructions
given to her

Apt #: 3 1) Patient will discuss any changes in 1) Update health history 1) Patient revealed any changes in
Date: 7/7/16 her health history since her last visit. her health history. goal met
Time Req: 1 hour
2) Patient will consent to todays 2) Patient consents to treatment 2) Patient consented to treatment.
treatment goal met

3) Patient will allow vitals to be 3) Vital Signs 3) Patient allowed vitals to be taken.
taken and understand why while goal met
following directions correctly
4) Chlorhexadine rinse 4) Patient consented to chlorhexadine
4) Patient will agree to use rinse. goal met
chlorhexadine rinse and understand
the reason for it. 5) Assesment completed on patient
16
5)Extraoral and Intraoral Exam and directions were followed during.
5) Patient will understand the need goal met.
for and extraoral and intraoral exam
and follow directions during 6)Hard tissue charting for changes 6) Hard tissue charting changes were
since last appointment updated and patient cooperated
6) Patient will understand the need to during. goal met
update the hard tissue charting and
cooperate during. 7) PHP 7) Patient understood reason for
finding PHP and understood the
7)Patient will understand the 8) Nitrous sedation on patient findings. goal met.
reasoning for finding a PHP and
understand the findings 9) Evaluate the need for local 8) Patient understood the benefits
anesthetic and explain the benefits and risks of Nitrous and asked any
8) Patients will understand the and risk associated with LA questions she had. goal met
benefits and risks of Nitrous and
discuss any concerns she has 10) Perform scaling and root planing 9)Patient understood the benefits and
on the UR quad using a cavitron and risk of local anethetic and discussed
9)Patient will understand the benefits hand instruments. any concerns about topiacl and local
and risk of local anesethic and will anesthetic and was open to using
discuss any concerns she has about 11) Patient Education, Have patient both types of anethetic. goal met
using topical and local anesthetic and demonstrate the Bass brushing
be open to using both types of technique 10)Patient followed all directions
anesthetic. a) Discuss options of an electric during scaling and root planing. goal
toothbrush met
10) Patient will follow all directions b) Evaluate patients current
during the scaling and root planing homecare routine to see if positive 11)Patient demonstrated the Bass
and will express any pain or changes are being made. brushing technique. goal met.
senstivity c) discuss the importance of a)Patient showed understanding
flossing of the benefits of an electric
11) Patient will demonstrate the Bass toothbrush. goal met
brushing technique 12) follow up on appointments made b)Patient understands the
a) Patient will understand the to the patient's general dentist for importance of a good homecare
benefits of an electric toothbrush restorative care. routine. goal met
b)Patient will understand the c)Patient understands the benefits of
importance of a good homecare 13) Give post-op instructions flossing. goal met
routine
c) Patient will understand the 12) Patient has not made follow up
benefits of flossing appointments with his dentist. goal
unmet.
17
12) Patient will have scheduled an
appointment with her dentist for 13) Patient followed and understood
restorative care all post op instructions given to him.
goal met
13) Patient will follow and
understand all post-op instructions
given to her

Apt #: 4 1) Patient will discuss any changes in 1) Update health history 1) Patient revealed any changes in
Date: 7/14/16 her health history since his last visit. her health history. goal met
Time Req: 1 hour
2) Patient will consent to todays 2) Patient consented to treatment.
treatment 2) Patient consents to treatment goal met

3) Patient will allow vitals to be 3) Vital Signs 3) Patient allowed vital to be taken
taken and understand why while and understood why. goal met
following directions correctly
4) Chlorhexadine rinse 4) Patient consented to chlorhexadine
4) Patient will agree to use rinse and understood the reason for
chlorhexadine rinse and understand it.goal met
the reason for it.
5) Patient understood the need for
5)Extraoral and Intraoral Exam extra and intra oral exam and
5) Patient will understand the need followed directions during. goal met.
for and extraoral and intraoral exam
and follow directions during 6)Hard tissue charting for changes 6) Hard tissue charting changes were
since last appointment made and patient cooperated during.
6) Patient will understand the need to goal met
update the hard tissue charting and
cooperate during. 7) PHP 7) Patient understood the reasoning
for finding a PHP and understood the
7)Patient will understand the 8) Nitrous sedation on patient findings. goal met.
reasoning for finding a PHP and
understand the findings 9) Evaluate the need for local 8) Patient understood the benefots
anesthetic and explain the benefits and risks of Nitrous and asked any
8) Patient will understand the and risk associated with LA questions she had. goal met
benefits and risks of Nitrous and
discuss any concerns she has 9)Patient understood the benefits and
risks of local anethetic and discussed
18
9)Patient will understand the benefits 10) Perform scaling and root planing concerns. goal met
and risk of local anesethic and will on the UL & UR quad using a
discuss any concerns he has about cavitron and hand instruments.
using topical and local anesthetic and 10)Patient followed all directoins
be open to using both types of 11) Patient Education during scaling and root planing of the
anesthetic. a) evaluate patients current homecare UL & UR quadrants and expressed
routine to see if positive changes are sensitivity. goal met
10) Patient will follow all directions being made. Reinforce brushing and
during the scaling and root planing flossing 11)Patient showed understanding of
and will express any pain or b)discuss the benefits of using a good oral homecare routine. goal
senstivity Chlorhexadine rinse at home. met
a)Patient showed understanding of
11) Patient will understand the need 12) follow up on appointments made the benefits of a good oral homecare
for good oral homecare to the patient's general dentist. routine. goal met
a) Patient will understand the b)Patient understands the benefits
benefits of a good homecare routine 13) Give post-op instructions of using a chlorhexadine rinse at
and understand why she needs to home. goal met
brush and floss correctly
b)Patient will understand the 12) Patient has not made follow up
benefits of using chlorhexadine rinse appointments with his dentist. goal
at home unmet.
12) Patient will have scheduled an
appointment with her dentist for 13) Patient followed and understood
restorative care all post-op instructions given to her.
13) Patient will follow and goal met
understand all post-op instructions
given to her

Apt #: 5 1)Patient will discuss any changes to 1) Patient revealed changes in her
Date: 8/25/16 her health history since his last visit health history. goal met
Time Req: 1 hour 1) Update patient health history
2)Patient will give consent to 2) Patient consented to treatment.
treament 2) Obtain patient consent for goal met
treatment
3) Patient will allow vital signs to be 3) Patient allowed vitals to be taken
taken and understand why. 3) Vital signs and understood the need. goal met

4) Patient will agree to use CHX 4) Chlorhexadine rinse 4) Patient concented to


rinse. chlorhexadine rinse. goal met
19
5) Extraoral and Intraoral exam
5)Patient will understand the need 5)Patient understood the need for
for an extraoral and intraoral exam extra and intra oral exam and
and will follow directions during 6) HTC followed directions during. goal met

6)Patient will reveal any dental work 6) Patient revealed dental work done
since last appointment and will 7) Full mouth periodontal probe, since last appointment. goal met
follow directions during periodontal classification, discuss
findings with patient 7)Patient understood the need to
7)Patient will understand the need to probe the whole mouth and
probe the whole mouth and will 8)PHP, discuss findings with patient understood the findings. goal met
understand why and the findings.
9) Nitrous sedation on patient 8)Patient does not yet understand the
8)Patient will understand the reasoning for a PHP or the findings.
reasoning for a PHP and understand goal met
the findings and following directions 10)PBI, gingivitis classification,
during discuss findings with patient
9) Patient understood the benefits
9) Patient will understand the and risk of nitrous and discussed any
benefits and risk of Nitrous and 11)deposit classification, discuss concerns she had. goal met
discuss any concerns she has findings with patient
10)Patient undersatnds her PBI or
10)Patient will understand her PBI 12) Extra-oral/Intra-oral pictures gingivitis classification. goal met
and gingivitis classifications. a) discuss any improvements/lack
there of with patient.
11)Patient understands the findings
11)Patient will understand the 13) Patient Education during deposit recognition and
findings during deposit recognition followed directions during. goal met
and follow directions during a) discuss with patient how
treatment and healing is progressing. 12)patient showed understanding of
12) Patient will show understanding the results of the pictures. goal met
of the results of the pictures 14)Discuss the need for a 3 month
SPM. 13)
13)Patient will show understanding a) patient showed understanding of
of patient education given the progression of her treatment and
a) patient will show b) discuss any areas that may healing. goal met.
understanding of the progression of need further attention or treatment.
his treatment and healing process. 14) Patient has not yet shown
c) reinforce proper brushing and understanding of the need for 3
20
14)patient will show understanding flossing techniques and frequencies. month SPM or commited to keeping
of the need for a 3 month SPM and the appointments. goal met
commit to keeping these b) patient understands the need
appointments. 15) perform full mouth coronal for further treatment. goal met
b) patient will show debridement c) patient has made changes in her
understanding of the reason for homecare routine. goal met
further treatment if necessary. 16) coronal polish, floss and fluoride
c) patient will reveal that she has varnish 15) Patient followed all directions
been brushing twice a day with a) give post-op instructions for during coronal debridement. goal
correct form and flossing once a day fluoride varnish met
with correct form
17) DDS signs prescription for CHX 16)Patient followed all direction
15)Patient will follow all directions a) Discussed with patient benefits during polish, floss and flouride. goal
during full mouth coronal and proper usage of CHX. met
debridement b) discussed with patient side a)Patient understands post op
effects of CHX rinse instructions for fluoride varnish. goal
16)Patient will follow all directions met
during the polishing, flossing and 18)
fluoride varnish a) discussed with patient tobacco 17) DDS signed prescription. goal
a)Patient will understand post-op use and its effects on the oral cavity met
instructions for fluoride varnish b) explained to patient how a) Patient understood proper usage
smoking cessation will help keep her and benefits of CHX. goal met.
17) Patient will be prescribed CHX mouth healthier b) Patient understood side effects
a) Patient will understand benefits c) discuss with patient discussing of CHX rinse. goal met
of CHX and proper use more in the future
b) Patient will understand side 17)
effects of longterm CHX rinse a) patient showed understanding of
tobacco use and its effects on the oral
18) cavity. goal met.
a) patient will show b)patient showed understanding of
understanding of tobacco use and its how smoking cessation will help
effects on the oral cavity. keep her mouth healthier. goal me.
b) patient will understand how c) patient agreed to discuss more
smoking cessation will help keep her in the future. goal met.
mouth healthier
c) patient will agree to discuss
more in the future

21
Apt #: 1) Patient will discuss any changes in 1) Update health history 1) Patient revealed changes in her
6 her health history since her last visit. health history. goal unmet

Date: 11/23/16 2) Patient will consent to todays 2) Patient consents to treatment 2) Patient consented to todays
Time Req: 1:00 treatment treatment. goal unmet
3) Vital Signs
3) Patient will allow vitals to be 3) Patient allowed vitals to be taken.
taken and understand why while goal unmet
following directions correctly 4) Chlorhexadine rinse
4) Patient consented to chlorhexadine
4) Patient will agree to use rinse. goal unmet
chlorhexadine rinse and understand
the reason for it. 5)Extraoral and Intraoral Exam 5) Assesment completed . goal
unmet.
5) Patient will understand the need
for and extraoral and intraoral exam 6)Hard tissue charting for changes 6) Changes in hard tissue charting
and follow directions during since last appointment completed. goal unmet

6) Patient will understand the need to 7) Completed patients PHP and


update the hard tissue charting and 7) PHP patient understood findings. goal
cooperate during. unmet.
8) Perform nitrous sedation on
7)Patient will understand the patient. 8) Patient understood the benefits
reasoning for finding a PHP and and risks of Nitrous and asked any
understand the findings 9) Perform full mouth debridement questions she had. goal unmet
with hand instruments.
8) Patient will understand the
benefits and risks of Nitrous Oxide 10) Patient Education, Have patient 19)Patient followed all directions
and will discuss any concerns she demonstrate the Bass brushing during full mouth debridement and
has. technique and c-shape flossing. expressed pain. goal unmet
a) discuss increasing brushing
9) Patient will follow all directions time to 2 minutes. Discuss options of 10)patient demonstrated the Bass
during the full mouth debridement an electric toothbrush technique and c-shape flossing. goal
and will express any pain or b) evaluate patients current unmet.
senstivity homecare routine to see if positive a)Patient showed understanding
changes are being made. of the benefits of brushing for 2min.
10) Patient will demonstrate the Bass c) discuss different flossing goal unmet
brushing technique and c-shape options inclusing waterpik and b)Patient understands the
22
flossing correctly. airflosser. importance of a good homecare
a) Patient wil understand the routine. goal unmet
benefits of brushing for 2 minutes 11) Follow up on appointment made c)Patient understand the benefits of
and also the benefits of an electric at patients general dentist. flossing and the different products
toothbrush available.goal unmet
b)Patient will understand the
importance of a good homecare 11) Patient has not made follow up
routine appointments with his dentist. goal
c) Patient will understand the unmet.
benefits of flossing and the different 12) coronal polish, floss and fluoride
products that may be used instead of varnish 16)Patient followed all direction
regular string floss a) give post-op instructions for during polish, floss and flouride. goal
fluoride varnish met
11) Patient will have scheduled an a)Patient understands post op
appointment with her dentist. 13) instructions for fluoride varnish. goal
a) discussed with patient tobacco met
12)Patient will follow all directions use and its effects on the oral cavity
during the polishing, flossing and b) explained to patient how 17)
fluoride varnish smoking cessation will help keep her a) patient showed understanding of
a)Patient will understand post-op mouth healthier tobacco use and its effects on the oral
instructions for fluoride varnish c) discuss with patient discussing cavity. goal unmet.
more in the future b)patient showed understanding of
13) how smoking cessation will help
a) patient will show keep her mouth healthier. goal
understanding of tobacco use and its unmet.
effects on the oral cavity. c) patient agreed to discuss more
b) patient will understand how in the future. goal unmet.
smoking cessation will help keep her
mouth healthier
c) patient will agree to discuss
more in the future

Apt #:
Date:
Time Req:
Apt #:
Date:
Time Req:
23
24