Periodontal Disease. Patient Profile Patient is a 68 year old male Health History Presents with...

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.