Periodontal Case Study Project

1. Periodontal Case Study Project Dental Hygiene Clinic II Cassandra Ligor

2. Patient Profile Health History : Dental History 45 year old Caucasian female. Non – contributory health history Job related stress No contraindications to TX ASA I Vital signs WNL No dental anxiety Routine 6 month re-care Brushes with soft tooth brush 2xd Flosses 1xd Uses night guard Grinds teeth

3. EXTRA ORAL AND INTRA ORAL FINDINGS Bilateral linea alba on the buccal mucosa Slight tori on the palate Petichiae on the orifice of the right tonsil Slight scalloped tongue and a short lingual frena. Attrition on teeth 22-27. 8 and 9 had chips on the incisal edge Class I occlusion. 70 % overbite and 3mm over jet Caries risk factors is moderate due to previous restorations and eats candy. No oral cancer risks patient never smoked. Oral habits are grinding at night and patient wears a night guard

4. Intra Oral Photos

5. Intra Oral Photos

6. Intra Oral Photos

7. Intra Oral Photos

8. Intra Oral Photos

9. Intra Oral Photos

10. Dental Chart

11. Perio Chart

12. Assessment findings BOP on 4, 30 , and 31 Plaque index was 16% on initial visit Supragingivalcalculus on 2,3,14,15,23-26 Subgingival on 2,3,13,14,15,29,27-23,18 and 18 Soft deposit on buccal and lingual of maxillary and mandibular premolars and molars. 4,5,12,13,18 faulty restorations Carious lesion on 3,18 and 19 Localized recession on buccal of 19, 20 and 21

13. Gingival Description Generalized pink, normal, knifelike margins, stippled tissue, with localized recession on teeth number 19, 20 and 21.

14. Factors Risk factors Contributory factors Stress- work related Hormones Faulty restorations Position of teeth/malocclusion Occlusal discrepancies Parafunctional habits-grinding clenching Calculus

15. Radiographs

16. Radiographs

17. Radiographs Slight/moderate horizontal bone loss on teeth number 4, 5 and 6. and slight/moderate horizontal bone loss on tooth number 31.

18. Radiographs 18 and 19 have slight/moderate vertical bone loss and there is slight triangulation throughout these x- rays.

19. Periodontal Diagnosis Generalized slight inactive chronic periodontitis, with localized active chronic periodontitis on # 4,30,31 AAP II

20. Treatment Plan

21. Procedures First visit completed indices and assessments. Second visit: review and update medical history and cursory exams. Biofilm index and reviewed self care and flossing techniques. Started debridement with power driven scaler. Third visit: review and update medical history and cursory exams. Biofilm index improved by 5%. Debridement with the power driven scaler, toothbrush, and fluoride trays.

22. Summary This patient was very compliant and visits the dentist regularly, so the calculus buildup wasn’t very severe. Scaling with the ultrasonic went very well although the patient experienced sensitivity on the upper left side, and lower right side. Most of the recession was on the left side of the mouth. Especially on the mandibular pre-molars. Although this patient has normal healthy gingiva, the AAP case type is II due to the amount of recession present, which was why the CAL’s were between 2 -3. After reviewing the x-rays there is not a lot of bone loss present, only slight on a few teeth, horizontal and vertical. This patient has taught me how important it is to look at the details when determining the case type and periodontal diagnosis. This was my first patient and I realize how the perio chart could use adjusting. For example the Gm’s on the posterior are 0 and since the papillae are not blunted it should be plus 1 or even 2. the dental chart also needs to be changed, with some of the watches on the restorations. This project really helped me to evaluate my work and see how much I have improved in perio and other dental hygiene services.