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DEH 23 Periodontal Case

DEH 23 Periodontal Case . Natalie Buzard Riverside Community College. 32 year old, married white male Chief Complaint- “to get my teeth cleaned.” Dental History- Ortho- 1990-1992 No current appliances Grinds at night-no pain Cleaning & DDS-7/07 FMX 11/07 at RCC. Medical History

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DEH 23 Periodontal Case

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  1. DEH 23 Periodontal Case Natalie Buzard Riverside Community College

  2. 32 year old, married white male Chief Complaint- “to get my teeth cleaned.” Dental History- Ortho- 1990-1992 No current appliances Grinds at night-no pain Cleaning & DDS-7/07 FMX 11/07 at RCC Medical History Childhood Vaccine- 6-7 Hep. B-1996, no titer Outpatient shoulder surgery- 7/07 Perkacet for 1 week for pain after surgery 7/07 No other Medications Patient Profile

  3. 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.

  4. 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

  5. Missing 1,16,17 &32 due to extraction at age 20. Restor:3-C-DO, 14-A-O, 15-C-O, 19-C-O, 20-C-O, 21-C-O, 22-C-IL, 28-C-O, 29-C-O, 30-C-DO, 31C-MO Tooth findings: cal on M15, dilaceration of mand. 1st molars No abnormal osseous findings Periodontal: trabecular pattern- consistent throughout Lamina dura- present and consistent throughout PDL space- present and consistent throughout Alveolar crest-1-2 mm below CEJ throughout Radiographic Findings

  6. 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

  7. 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 Dental Health Education

  8. 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 polish-L#27&L#25, fluoride Appt 4- 4 mos. recare Goals and Treatment Plan

  9. Periodontal Project- Pictures Before After

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