Transcript Last dental exam

P ERIODONTAL C ASE S TUDY
DEH-23
P ATIENT P ROFILE
Name: Daisy Duke
Age: 46
Ethnicity: Caucasian
Marital status: Married
Occupation: Manager
Chief Complaint: I need my teeth cleaned
D ENTAL I NFORMATION
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. 2006
Last Dental x-rays: Dec. 2007 (FMX)
Date of last teeth cleaning: Aug. 2007
Previous Dentist: Dr. Blackmon
P ATIENT P ROFILE
C ONTINUED
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 carpultunel
Gastrointestinal/ Genito Urinary: She
gets frequent cold sores
P ATIENT P ROFILE
C ONTINUED
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
P ATIENT P ROFILE
C ONTINUED
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)
C LINICAL F INDINGS
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.
C LINICAL F INDINGS
C ONTINUED
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.
C LINICAL F INDINGS
C ONTINUED
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
D ENTAL H EALTH
E DUCATION
The patient has been taking good care of
her mouth since she had her crowns placed
and she flosses daily. So I will just reenforce 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.
R ATIONAL FOR C ASE
S ELECTION AND G OALS
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.
T REATMENT P LAN
Apt 1
Assessments
Apt 2
DDS exam
Second check in
Apt3
UR quad scale
w/anesthesia
Apt 4
LR quad scale w/
anesthesia
Apt 5
UL quad scale w/
anesthesia
Apt 6
LL quad scale w/
anesthesia
Apt 7
4-6 wk re-evaluation
Fluoride
Selective polish
I NTRAORAL P ICTURES
Facial
Lingual Mandibular
Lingual Maxillary