Periodontal Project WLAC 2010 Betty Tran Ruzan Ayvazyan. Personal History. Name : Pedro Zamora Age : 30 yrs old Sex : Male Race : Hispanic Occupation : Unemployed Marital Status : Single. Medical History. Past History:
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Name: Pedro Zamora
Age: 30 yrs old
Marital Status: Single
- Pt states having previous malnutrition due to lack of shelter and food.
- Prior physical trauma of head and mouth that resulted in the fracture of tooth #8, #9, #10
- Systemic: Uncontrolled hypertension, history of substance use, smokes tobacco for the past 10 years
- Present illnesses: Pt states that he currently has an eating disorder where he over eats and has become obese.
Current Medication: None
Baseline Vitals: 134/94 = 1st reading
128/90= 2nd reading
**Refer to physician
Last dental visit: 1997
Previous restorations: #8,#9,#10 PFM
Amalgam #3 O
Present status: New pt for dental hygiene services
CC: Would like crown re-cemented #10
Pt has several clinical caries
- #10 Tx planned for RCT due to recurrent decay. New crown must be made
- Radiographs were undiagnosable
- Pt is at HIGH RISK for caries
Intra oral:Slight attrition on lower anteriors
Abrasion on #6, #11, #12, #21, #22, #27, #29
TMD Evaluation:Asymptomatic clicking on right TMJ
Mandibular jaw slightly deviates to the right upon opening.
Only brushes 1x a day and never flosses
Knowledge of periodontal disease:Unaware
Objective:Educate pt about the importance of stabilizing the present periodontal condition. Provide proper OH aids to best suit his needs.
Aids:Demonstrated modified bass w/manual TB, proper flossing techniques SonicCare toothbrush, floss holder, Antimicrobial rinse.
Barriers:Poor dexterity and motivation, lack of shelter, transportation and employment.
Bilateral Class I molar and canine relationship
Calculus:Generalized medium-heavy tenacious calculus
Restorations:#8,#9,#10 ill-fitting margins
Pocket depths:Generalized 3-4 mm w/localized 5-6 mm on posteriors and #8MB and #9 DB
Mobility:+ on teeth #7-11 and #23-27
Furcations:Buccal Class I #2,#3,#14,#15,#31,#30
Buccal Class II: #19
Diagnosis:Generalized Chronic Moderate Periodontitis modified by smoking and perpetuated by plaque
Prognosis:clinically = GOOD, however…
+ poor oral hygiene
4 quads SRP w/ local anesthesia
Re-evaluation in 4 weeks to assess
Emphasis on Smoking Cessation
Appointment #1 (12/03/09)
Initial exam, FMX, intraoral photographs , full mouth probing, indices were taken, OHI, #10 PFM re-cemented by supervising dentist.
Appointment #2 (12/10/09)
Morning: Initiated smoking cessation, re-assessed OH – brushing & flossing,
LLQ SRP w/ local anesthesia.
Afternoon: ULQ SRP w/ local anesthesia
Appointment #3 (1/21/10)
Morning: ULQ SRP w/ local anesthesia,
re-enforce OH and smoking cessation.
Afternoon: LLQ SRP w/local anesthesia,
2% NaF varnish was applied, CAMBRA Assessment, nutritional counseling
Appointment #4 (2/18/10)
Re-evaluation, full mouth probing, intraoral photographs, case study models, and indices were taken. Fine scaling to remove residual calculus.
Probing: Generalized 3-4 mm w/localized 5 mm on #8MB, #31DB, #17MD
- Pt had a good understanding of the tx that was completed and was excited to participate. However, pt’s circumstances made it difficult to maintain compliance.
- Complications during treatment:
* Pt did not have cell phone or number for direct contact
* Pt was dependant on friends driving him to and from appt
* No Show on 2 appts.
- We did our best to reschedule broken appts
- Provided pt with Sonicare TB as well as ACT daily fluoride rinse, and other OH aids so pt would not have to buy on their own.
- It was difficult to attain the ideal resolution because pt was not compliant with smoking cessation & medical consults/check-ups.