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Patient A

Patient A. By: Jennifer Klocki. Pt is a 51 year old widowed female Pt is here for a cleaning. Last Dental Exam may 2006 Last cleaning may 2007 Pt presents with dry and sensitive mouth. Lets Get To Know Patient A. Pt states she has 3 rd stage heart failure diagnosed 5 years ago

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Patient A

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  1. Patient A By: Jennifer Klocki

  2. Pt is a 51 year old widowed female Pt is here for a cleaning Last Dental Exam may 2006 Last cleaning may 2007 Pt presents with dry and sensitive mouth. Lets Get To Know Patient A

  3. Pt states she has 3rd stage heart failure diagnosed 5 years ago Pt states she used phen-phen Pt states she has a slight allergy to iodine Pt had C-section in 1983 Pt had Gastric bypass in 2007 Pt is taking Coreg for heart failure Accupril for congestive heart failure Vicodine for pain ASA II Medical History

  4. Med Consult • 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.

  5. E&I findings • 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

  6. Lichen Planus

  7. Radiographic Findings • 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

  8. 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 Perio Exam

  9. Periodontal Classification • ADA III • AAP Generalized moderate chronic periodontitis due to plaque and calculus. • Calculus Code is medium

  10. Rational • Learned: • Scaling furcation • Instrumentation skills • Specialized OHI • Specialized needs such as tepe brush and mouthwashes

  11. Strategies to Improve • 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

  12. Appt 1 assessments & radiographs 4/10 Appt 2 DDS exam, 2nd Check in 4/10 Appt 3 PI, OHI, pictures,#2&3, anesthesia 4/24 Appt 4 # 4-8 anesthesia 4/29 Treatment Plan

  13. Appt 5 # 25-31 anesthesia 4/30 Appt 6 # 14 &15, tepe brush, anesthesia 5/7 Appt 7 #13, irrigated anesthesia 5/20 Appt 8 #11-9,18,19 irrigated #18 & 19 anesthesia 5/21 Appt 9 #20-24 anesthesia Re eval, fluoride, selective polish Treatment Plan cont.

  14. Pre Operative Pictures Facial Lingual

  15. Patient A The End

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