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Periodontal Case Report: Initial Phase

Periodontal Case Report: Initial Phase . Anna Trask November 30, 2011 . Objectives. Introduction Medical & Dental History Assessments Treatment Plan Food Diary Conclusion . Introduction . Catherine (62 year old female) Registered Nurse Came to clinic for a dental cleaning .

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Periodontal Case Report: Initial Phase

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  1. Periodontal Case Report: Initial Phase Anna Trask November 30, 2011

  2. Objectives • Introduction • Medical & Dental History • Assessments • Treatment Plan • Food Diary • Conclusion

  3. Introduction • Catherine (62 year old female) • Registered Nurse • Came to clinic for a dental cleaning

  4. Medical History • BLOOD PRESSURE • 112/78 • ASA II • Systemic lupus erythematosus (SLE) • Mitral valve prolapse (MVP) • Pre-med required • High blood pressure • Allergy – penicillin and aspirin • Last MD – October 2011 for physical. No comps. • MEDICATIONS • Enalipril for high blood pressure

  5. Medications Side Effects Dental Considerations • Headache • Dizziness • Orthostatic Hypotension • Use vasoconstrictor with caution • Monitor vital signs

  6. Dental History • Last dental visit was February 2011 • Exam, cleaning, radiographs • Reaction to anesthesia (passed out) • Here for root planing as recommended by her dentist. • Couldn’t afford at dentist

  7. ASSESSMENTS Prominent lingual veins Fistula below #25 & 26 Gingiva: Gen. mild red margins Gen. rolled margins Gen. Soft Gen. Stippling

  8. Assessment (cont.) • Normal (Class I) Occlusion • 2 mm overjet • Normal Overbite • Brush 3xday with power brush • Uses regular floss 1xday • Proxy brush & mouth rinse occasionally • Fluoride in toothpaste

  9. Restorative Charting

  10. Periodontal Assessment IIB Moderate Gen. 3-6 mm posterior Gen 2-5 mm anterior Recession Gen. 1-4 mm Furcations Class 1 - #2, 15, 17, 18, 30 Mobility #7-11 & 24-26 Light BOP Mod plaque Light stain (md.anteriors) Calculus Class: 3

  11. Radiographs

  12. Risk Assessments • Periodontal Risk Assessment • Risk Score: 3 (moderate risk) • Disease State: 31 – mild to moderate periodontitis • Caries, Root and Fracture Risk Assessment • Caries Risk Score: 1 (low) • Fracture Risk Score: 1 (low) • Root Surface Risk Score: 1 (low)

  13. Plaque Index • Score 1.3 • Fair plaque removal • Needs improvement

  14. Gingival Index • Score 1.0 • Fair – good tissue condition • Light Bleeding

  15. Front

  16. Right Side

  17. Left Side

  18. Maxillary Arch

  19. Mandibular Arch

  20. Treatment Plan • Scaling & Root Planing – 4 quads • Oral Hygiene Instruction • TB – mod bass • DF – “C” wrap • Proxy brush • Nutritional Counseling • Selective polish • Fluoride – Neutral Appointments: • Assessments DDS Eval OHI – T.B. – mod bass • Assessments • Assessments • Assessments OHI – Review T.B. D.F. – “C’ wrap Scale UR Quad OHI – Review T.B. & D.F. Proxy brush Scale LR Quad OHI –Review All Scale UL Quad & LL Quad Fluoride – neutral

  21. Treatment Goals • Remove deposits • Reduce pocket depths • Improve gingival health

  22. 3-Day Food Diary • Returned a few weeks after receiving it. • Will discuss more nutrition at a following appt.

  23. Summary Good learning case - IIB Mod Calculus Class 3 Needs improvement on oral hygiene. Stay tuned for completion phase!!

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