Deh 23 periodontal case
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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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Deh 23 periodontal case

DEH 23 Periodontal Case

Natalie Buzard

Riverside Community College


Patient profile

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


Clinical findings e i exam

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

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 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


Ada and aap

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

Dental Health Education


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 polish-L#27&L#25, fluoride

Appt 4- 4 mos. recare

Goals and Treatment Plan


Periodontal project pictures

Periodontal Project- Pictures

Before

After


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