Transcript Periodontal Disease Patient Profile Patient is a 68 year old male

Periodontal Disease
Patient Profile
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Patient is a 68 year old male
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Health History
Dental History
Last dental visit was in January
2014
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Presents with High Blood
pressure
Orthodontics 55 years ago
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Medications: allertec and ¼
grain aspirin, multivitamin
Extracted wisdom teeth 50
years ago
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Congenital heart defect, no
per-medication required
Occasional canker sores
Allergies to dust, mold,
feathers, ragweed and gluten
Flosses once a day
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History of arthritis
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Allergy to Penicillin=causes
rash
Electric toothbrush once a day
ASA III
Extra and Intra Oral Exam Findings
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HEAD, NECK: 4 mm round brown mole behind left ear.
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LIPS: fordyce granules.
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MUCOSA: linea alba. varicosities in the corner of the mouth.
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PALATE: high vaulted palate
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FAUCES (TONSILS, PHARYNX): Fauces red . pt states it is due to post
nasal drip. tonsils absent.
TONGUE:coated
Dental Exam Findings
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Intrinsic stain: amalgam #14
Occlusion:
Attrition: generalized slight attrition on
anterior
Molar right: Class I
Abrasion: generalized abrasion
Canine right: class I
Calcification: tooth #7 around a
restoration
Canine left → Class II
Overbite: coronal 1/3 slight
Over jet: 4 mm
Labio/linguoversion: mild labioversion
#21 & 25. Mild linguoversion #22 &
27. Crowding of all anteriors
Molar Left: Class I
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
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Class I furcation tooth #31
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Mucogingival involvement: #12, 20, 21, 22, 23, 25, 26, 27, 29
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Bleeding on probing: #2, 4, 5, 12, 21, 23 & 27
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Periodontal risk factors: stress
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Periodontal contributory factors: calculus, faulty restorations, food impaction,
position of teeth/malocclusion, and history of orthodontics
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Biofilm index: 56%
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Soft deposit generalized slight on the cervical 1/3
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Extrinsic stain generalized moderate pits, fissures, and linguals of mandible
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Generalized ledges of supra and subgingival calculus
Gingival Description
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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
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#31 & 18 20% bone loss.
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Films are dark and hard to read.
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Date of radiographs 4/10/12
Periodontal Diagnosis
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Generalized moderate active chronic periodontitis
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AAP Case Type: III
Treatment Plan
Procedures
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First visit:
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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
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Third visit:
Fourth visit;
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Medical history
reviewed
Medical history
reviewed
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Cursory
Extra/intraoral
exam
Cursory
Extra/intraoral
exam
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Continued to work
on periodontal
charting
Finished periodontal
charting
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Photos taken for
periodontal project
Received FMX from
4/12
Procedures
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Fifth visit:
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Medical history reviewed
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Cursory Extra/intraoral exam
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Finished periodontal assessment
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Performed deposit assessment
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Bio film index 56%
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Completed treatment plan
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Debridment: started power driven maxillary right
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Bio film removal: tooth brush method & interproximal
brush
Procedures
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Sixth visit:
Seventh visit:
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Medical history reviewed
Medical History: reviewed
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Cursory EOE & IOE
Cursory EOE & IOE
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Biofilm index: 50%
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Debridment: hand
instrumentation on
maxillary right and
anterior sextant
Debridment: power
instumentation
maxillary left sextant
and mandible
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Other Dental Hygiene
Services: Reviewed oral
Home care
Soft deposit: tooth brush,
selective polish and
floss
Applied 5% NaFl varnish
DH report was given to
patient
Summary
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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.