PERIODONTAL CASE STUDYDEH-23

PATIENT PROFILE

Name: Daisy DukeAge: 46Ethnicity: CaucasianMarital status: MarriedOccupation: Manager

Chief Complaint: I need my teeth cleaned

DENTAL INFORMATION

She does get blisters and sores on her mouth (last one was in Feb. 2007) and she does clench and grind her teeth at night.

Last dental exam: Aug. 2006Last Dental x-rays: Dec. 2007 (FMX)Date of last teeth cleaning: Aug. 2007Previous Dentist: Dr. Blackmon

PATIENT PROFILE CONTINUED

Health History: No cardiovascular Problems, Respiratory problems, Head and neck problems, Hema/Endo/Immune disorders, or psychological disorders.

Social life: She did quit using tobacco 8 years ago, and does drink alcohol once a month.

Neuromuscular/CNS: She has carpultunelGastrointestinal/ Genito Urinary: She gets frequent cold sores

PATIENT PROFILE CONTINUED

Have you had or have you taken: She did take OTC diet pills in the 70’s, and had her childhood vaccinations.

Family History: Her grandfather and uncles had colon cancer and are deceased from the disease

Allergies: She is allergic to metals in her ear piercings and to tide detergent

PATIENT PROFILE CONTINUED

Hospitalizations and emergency room visits: Child birth in 1985 and 1988 and for head trauma in 1983

Medications: Ibuprofen 800mg taken for carpultunel pain (last taken in Dec. of 2007)

CLINICAL FINDINGS

E & I: The only possible pathological finding was a 1.5mmx1mm red lesion on the patient’s nose.

Periodontal Exam: The patient has probing depths of generalized 2’s and 3’s with localized 1’s on the direct lingual surface of teeth #23-#26. MBI: 14%, BOP: 24%, and recession on many teeth in her mouth.

CLINICAL FINDINGSCONTINUED

Radiographic Exam: The patient has 12 crowns, 5 root canals, 3 composite restorations, and 2 amalgam restorations.She has 15 areas in her mouth with 1mm of bone loss and no areas of possible decay.

CLINICAL FINDINGSCONTINUED

Calculus Code: Medium

ADA: Generalized II Localized III

AAP: Generalized slight chronic perio. due to plaque and calculus and localized moderate perio. due to plaque and calculus

DENTAL HEALTH EDUCATION

The patient has been taking good care of her mouth since she had her crowns placed and she flosses daily. So I will just re-enforce good brushing technique with her and show her how to use her power toothbrushes (rota-dent and sonicare) to clean her teeth properly especially in the areas where she has crowns, because this is more than likely the reason for her higher than satisfactory BOP and MBI scores.

RATIONAL FOR CASE SELECTION AND GOALS

I decided to choose this patient because she has many crowns in her mouth and I think that she could benefit from good oral hygiene instructions on how to clean the areas in her mouth with restorations.

The Goals for this patient include helping her to maintain good oral hygiene, learn more ways to care for he restorations, and complete a full mouth scale on her.

TREATMENT PLAN

Apt 1Assessments

Apt 2DDS examSecond check in

Apt3UR quad scale w/anesthesia

Apt 4LR quad scale w/ anesthesia

Apt 5UL quad scale w/ anesthesia

Apt 6LL quad scale w/ anesthesia

Apt 74-6 wk re-evaluationFluorideSelective polish

INTRAORAL PICTURES

Facial

Lingual Mandibular

Lingual Maxillary