Transcript Periodontal Project

DEH 23 Periodontal Case
Natalie Buzard
Riverside Community College
Patient Profile
 32 year old, married
 Medical History
white male
Childhood Vaccine- 6-7
Hep. B-1996, no titer
 Chief Complaint- “to
Outpatient shoulder
get my teeth cleaned.”
surgery- 7/07
 Dental HistoryPerkacet for 1 week for
Ortho- 1990-1992
No current appliances
Grinds at night-no pain
Cleaning & DDS-7/07
FMX 11/07 at RCC
pain after surgery 7/07
No other Medications
Clinical Findings- E&I exam
 E: 6mm scar below lip, 15mm and 30mm scar
on left side of neck- pt. visited dermatologist in
2006- abnormal collagen synthesis and
extremely sensitive skin.
 I: bilateral mandibular tori, palatal torus, bilateral
linea alba, bilateral Fordyce granules, 2mm lip
bite on labial mucosa between #8 & 9,
keratinization on buccal mucosa at occlusal
plane due to cheek biting.
Periodontal Evaluation
Assessments:
Gingival Des: Free: Gen PSFS, Loc red,
edematous, bulbous and shiny Attach: Gen PFS
Loc red on ant. Mandibular teeth
MBI: 12.5%
BOP: 14.3% with gen. probing depth of 2-3, loc.
4 on M31 and M15
Recession- 1mm on
Mobility: + on 6-11, 26-23
Fremitus: + on 7-9 Furcations: None
RCC Calculus Code: Light/Medium
Radiographic Findings
 Missing 1,16,17 &32 due
 Periodontal:
to extraction at age 20.
trabecular pattern Restor:3-C-DO, 14-A-O,
consistent throughout
15-C-O, 19-C-O, 20-C-O,
Lamina dura- present
21-C-O, 22-C-IL, 28-C-O,
and consistent
29-C-O, 30-C-DO, 31Cthroughout
MO
PDL space- present
 Tooth findings: cal on M15,
and consistent
st
dilaceration of mand. 1
throughout
molars
Alveolar crest-1-2 mm
 No abnormal osseous
below CEJ throughout
findings
ADA and AAP
ADA: I
AAP: Slight Gingivitis due to plaque and
calculus
RCC Calculus Code: Light/medium
Rationale for Selection: Compliant Patient
with Light/Medium Calculus
Dental Health Education
 Patient flosses 1x per
week
 Taught “C” flossing
technique
 Encouraged patient to
floss 3x per week
 Patient brushes daily
Taught Bass Brushing
Technique
Encourage pt. to brush
at least 2x per day
Goals and Treatment Plan
Goals
 Reduce BOP to 7%
 Increase flossing to
3x/week
Treatment Plan
 Appt 1- Assessments,
DDS exam
 Appt 2- 2nd check-in,
OHI, PI, ULQ
 Appt 3, LLQ, URQ,
LRQ, selective polishL#27&L#25, fluoride
 Appt 4- 4 mos. recare
Periodontal Project- Pictures
Before
After