Transcript Perio Case

Patient A
By: Jennifer Klocki
Lets Get To Know Patient A
Pt is a 51 year old
widowed female
 Pt is here for a
cleaning
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Last Dental Exam
may 2006
 Last cleaning may
2007
 Pt presents with
dry and sensitive
mouth.
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Medical History
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Pt states she has 3rd
stage heart failure
diagnosed 5 years ago
Pt states she used phenphen
Pt states she has a slight
allergy to iodine
Pt had C-section in 1983
Pt had Gastric bypass in
2007
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Pt is taking Coreg for
heart failure
Accupril for congestive
heart failure
Vicodine for pain
ASA II
Med Consult
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Med consult was set to the physician who’s
response was, pt is healthy enough to
undergo proposed treatment and does not
require premed, but limit the amount of
vasoconstrictor.
E&I findings
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Generalized cratered free gingiva.
Bi Lateral lichen planus
7X3 macule on right side of the soft palate
and 3X6 macule on the upper left lip
8X3 nodule on the left pharyngeal arch
Was referred to her dentist for further
evaluation
Lichen Planus
Radiographic Findings
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Areas of concern: recurrent decay on
#12,and 15, #31 M crack with decay
Calculus: not visible on radiographs
Bone Loss:3-4 mm bone loss
Perio Exam
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MBI 3%, BOP 23%
Pocket depth: Loc
7(MB13), 5, 6 &Gen 4
Recession up to 2mm
gen. furcation areas
Mobility class III(2),- I
Muco Ging defect,24
&29
Furcation: class II 13
areas
Periodontal Classification
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ADA III
AAP Generalized moderate chronic
periodontitis due to plaque and calculus.
Calculus Code is medium
Rational
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Learned:
 Scaling furcation
 Instrumentation skills
 Specialized OHI
 Specialized needs such as tepe brush
and mouthwashes
Strategies to Improve
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Systemic & Oral risk factors: Bone loss,
Furcations, Medications and Mucogingival
defect.
Education Strategies: Bass, flossing, inter
dental brush
Goal decrease pocket depth and BOP
3 month recall
Treatment Plan
Appt 1
assessments &
radiographs 4/10
 Appt 2 DDS exam,
2nd Check in 4/10
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Appt 3 PI, OHI,
pictures,#2&3,
anesthesia 4/24
 Appt 4 # 4-8
anesthesia 4/29
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Treatment Plan cont.
Appt 5 # 25-31
anesthesia 4/30
 Appt 6 # 14 &15,
tepe brush,
anesthesia 5/7
 Appt 7 #13,
irrigated
anesthesia 5/20
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Appt 8 #11-9,18,19
irrigated #18 & 19
anesthesia 5/21
 Appt 9 #20-24
anesthesia
 Re eval, fluoride,
selective polish
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Pre Operative Pictures
Facial
Lingual
Patient A
The End