Periodontal Case Study Project Dental Hygiene Clinical Practice II

Patient Profile 18 year old Hispanic male Health history reveals: No medications Vitals signs WNL ASA class I Dental history reveals: Brushing with a medium toothbrush 1x day (AM) Flosses once in a while Last dental visit dated 6 months ago

Extra Oral and Intra Oral Findings Mucosa: Gingival pigmentation Frena: Max skin tag Alveolar ridges: Keratinized on distals of #’s18 and 31 Attrition: Slight attrition on #”s 4,6,7,10,11,22- 27 Fluorosis: Generalized Overbite: Slight 25% Overjet: 3mm Labio/linguoversion: Labioversion #’s 8 & 9 Torsoversion: #’s 21 & 28 Angles classification: Tendency to class III (molar & canine right) Tendency to class I (molar & canine left)

Intra Oral Photos

Intra Oral Photos

Intra Oral Photos

Dental Chart

Periodontal Charting

Periodontal Evaluation

Assessments Findings Class I furcation on the buccal aspect of tooth #15 No mobility or mucogingival involvement BOP was observed on #’s 3,4,5,8,11,12,14,15,20,21,28,30 Slight spicules of supragngival calculus on all maxillary and mandibular teeth Generalized spicules of subgingival calculus on the mandible with localized spicules on #’s 2,3,12,14,15 Generalized slight biofilm interproximally. Plaque Control Record was 9% No stains Defective sealants on #’s 3,19 & 30 with a watch on tooth #14 Teeth #’s 1,17 & 32 are partially erupted

Gingival Description Generalized pigmented, thickened, spongy, slightly enlarged papillae on the maxillary and mandibular anteriors with stippled tissue.

Contributory Factors: Nutritional deficiencies Obesity: Yes Periodontal Risk Factors: N/A

Radiographs Generalized slight bone loss

Radiographs

Radiographs

Radiographs

Periodontal Diagnosis Generalized slight active chronic periodontitis AAP Case Type: II

Procedures First visit Medical History, EOE, IOE, Vital Signs, Dental Charting and GM(maxillary) Second visit RMH, EOE, IOE, Vital Signs, GM, periodontal exam Plaque index & education - Reviewed brushing technique using a modified bass method Third visit RMH, EOE, IOE, Vital Signs, Deposit Assessment Plaque index and education -Reviewed brushing technique and introduced flossing technique Debridement of the maxillary right using mgnetostrictive power inserts (XT Modified universal) then followed by hand instrumentation Fourth visit FMX

Procedures Fifth visit RMH, EOE, IOE, Vital Signs Plaque index and home care -Both brushing and flossing technique have improved; patient is now using a soft toothbrush Re-asses URQ Debridement of the maxillary left using magnetostrictive power inserts (XT Modified universal) then followed by hand instrumentation Sixth visit -Patient is aware of proper brushing technique and is still working on “hugging” not “snapping” the floss when flossing Debridement of the mandible using magnetostrictive power inserts (XT Modified universal) then followed by hand instrumentation Biofilm removal with toothbrush Fluoride treatment with Oral B Neutral Foam (2% sodium fluoride), 4 minutes.

Treatment Plan

Re-evaluation

Summary This periodontal case was definitely a personal challenge. He was my first patient as a new second semester dental hygiene student. It was a gratifying experience because I was involved with the learning process with my patient. He presented with slight active chronic periodontitis, which will hopefully not progress due to the patients newly acquired knowledge of proper tooth brushing/flossing and the impact of oral health systemically. From this particular case I learned that Right and Left After Five Modified inserts could have also been used for debridement. Not only the XT modified, since the patient presented with light calculus accumulation. When detecting calculus, I also have to remember the contact area. I kept doubting myself when exploring and thought it might have been residual calculus.