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Periodontal Disease
Patient Profile
Patient is a 68 year old male
Health History
Presents with High Blood pressure
Medications: allertec and ¼ grain aspirin, multivitamin
Congenital heart defect, no per-medication required
Allergies to dust, mold, feathers, ragweed and gluten
History of arthritis
Allergy to Penicillin=causes rash
Dental History
Last dental visit was in January 2014
Orthodontics 55 years ago
Extracted wisdom teeth 50 years ago
Occasional canker sores
Electric toothbrush once a day
Flosses once a day
ASA III
Extra and Intra Oral Exam Findings
HEAD, NECK: 4 mm round brown mole behind left ear.
LIPS: fordyce granules.
MUCOSA: linea alba. varicosities in the corner of the mouth.
PALATE: high vaulted palate
FAUCES (TONSILS, PHARYNX): Fauces red . pt states it is due to post nasal drip. tonsils absent.
TONGUE:coated
Dental Exam Findings
Intrinsic stain: amalgam #14
Attrition: generalized slight attrition on anterior
Abrasion: generalized abrasion
Calcification: tooth #7 around a restoration
Overbite: coronal 1/3 slight
Over jet: 4 mm
Labio/linguoversion: mild labioversion #21 & 25. Mild linguoversion #22 & 27. Crowding of all anteriors
Occlusion:
Molar right: Class I
Molar Left: Class I
Canine right: class I
Canine left → Class II
Caries risk factors: previous restorations
Oral Habits: bruxism
Intra Oral Photographs
Intraoral Photographs
Intraoral Photographs
Intraoral Photographs
Dental Chart
Periodontal Chart
Periodontal Evaluation
Assessment Findings
Class I furcation tooth #31
Mucogingival involvement: #12, 20, 21, 22, 23, 25, 26, 27, 29
Bleeding on probing: #2, 4, 5, 12, 21, 23 & 27
Periodontal risk factors: stress
Periodontal contributory factors: calculus, faulty restorations, food impaction, position of teeth/malocclusion, and history of orthodontics
Biofilm index: 56%
Soft deposit generalized slight on the cervical 1/3
Extrinsic stain generalized moderate pits, fissures, and linguals of mandible
Generalized ledges of supra and subgingival calculus
Gingival Description
Maxilla is generalized pink, spongy, rounded, slightly edematous margins with localized redness #3, 8 & 12 with localized stippled, fibrotic with overlying edematous tissue on the anteriors.
Mandible is generalized marginal redness, rolled, shiny, spongy, edematous tissue with McCall's Festoons on #4, 5, 21 & 28.
Radiographs
Radiographic findings
#31 & 18 20% bone loss. Films are dark and hard to read. Date of radiographs 4/10/12
Periodontal Diagnosis
Generalized moderate active chronic periodontitis AAP Case Type: III
Treatment Plan
Procedures First visit:
Reviewed and updated medical history
Sent medical consult regarding high blood pressure
Performed extraoral exam and intraoral exam.
Started Dental chart
Second visit: Reviewed medical
history Cursory
Extra/intraoral exam.
Finished dental charting
Started periodontal charting
Procedures
Third visit: Medical history
reviewed Cursory
Extra/intraoral exam
Continued to work on periodontal charting
Photos taken for periodontal project
Fourth visit; Medical history
reviewed Cursory
Extra/intraoral exam
Finished periodontal charting
Received FMX from 4/12
Procedures
Fifth visit: Medical history reviewed
Cursory Extra/intraoral exam
Finished periodontal assessment
Performed deposit assessment
Bio film index 56%
Completed treatment plan
Debridment: started power driven maxillary right
Bio film removal: tooth brush method & interproximal brush
Procedures
Sixth visit: Medical history reviewed
Cursory EOE & IOE
Biofilm index: 50%
Debridment: hand instrumentation on maxillary right and anterior sextant
Other Dental Hygiene Services: Reviewed oral Home care
Seventh visit: Medical History:
reviewed
Cursory EOE & IOE
Debridment: power instumentation maxillary left sextant and mandible
Soft deposit: tooth brush, selective polish and floss
Applied 5% NaFl varnish
DH report was given to patient
Summary
It was difficult to assess this patient due to my inexperience and the extended time in between patient visits. I would have liked to reevaluate him to see if my probing depths were accurate from the first time.
The patient will not let me retake pictures and will not come back for re-evaluation
I still believe this patient to have generalized active chronic periodontitis.