DEH 23 Periodontal Case Natalie Buzard Riverside Community College.

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Presentation transcript:

DEH 23 Periodontal Case Natalie Buzard Riverside Community College

Patient Profile 32 year old, married white male Chief Complaint- “to get my teeth cleaned.” Dental History-  Ortho  No current appliances  Grinds at night-no pain  Cleaning & DDS-7/07  FMX 11/07 at RCC Medical History  Childhood Vaccine- 6-7  Hep. B-1996, no titer  Outpatient shoulder surgery- 7/07  Perkacet for 1 week for pain after surgery 7/07  No other Medications

Clinical Findings- E&I exam E: 6mm scar below lip, 15mm and 30mm scar on left side of neck- pt. visited dermatologist in abnormal collagen synthesis and extremely sensitive skin. I: bilateral mandibular tori, palatal torus, bilateral linea alba, bilateral Fordyce granules, 2mm lip bite on labial mucosa between #8 & 9, keratinization on buccal mucosa at occlusal plane due to cheek biting.

Periodontal Evaluation Assessments:  Gingival Des: Free: Gen PSFS, Loc red, edematous, bulbous and shiny Attach: Gen PFS Loc red on ant. Mandibular teeth  MBI: 12.5%  BOP: 14.3% with gen. probing depth of 2-3, loc. 4 on M31 and M15  Recession- 1mm on  Mobility: + on 6-11,  Fremitus: + on 7-9 Furcations: None  RCC Calculus Code: Light/Medium

Radiographic Findings Missing 1,16,17 &32 due to extraction at age 20. Restor:3-C-DO, 14-A-O, 15-C-O, 19-C-O, 20-C-O, 21-C-O, 22-C-IL, 28-C-O, 29-C-O, 30-C-DO, 31C- MO Tooth findings: cal on M15, dilaceration of mand. 1 st molars No abnormal osseous findings Periodontal:  trabecular pattern- consistent throughout  Lamina dura- present and consistent throughout  PDL space- present and consistent throughout  Alveolar crest-1-2 mm below CEJ throughout

ADA and AAP ADA: I AAP: Slight Gingivitis due to plaque and calculus RCC Calculus Code: Light/medium Rationale for Selection: Compliant Patient with Light/Medium Calculus

Dental Health Education Patient flosses 1x per week Taught “C” flossing technique Encouraged patient to floss 3x per week Patient brushes daily  Taught Bass Brushing Technique  Encourage pt. to brush at least 2x per day

Goals and Treatment Plan Goals Reduce BOP to 7% Increase flossing to 3x/week Treatment Plan Appt 1- Assessments, DDS exam Appt 2- 2 nd check-in, OHI, PI, ULQ Appt 3, LLQ, URQ, LRQ, selective polish- L#27&L#25, fluoride Appt 4- 4 mos. recare

Periodontal Project- Pictures BeforeAfter