Luis F. Moreno

Patient History  Age: 63  Sex: Female  Race: Caucasian  Occupation: Accountant  Marital status: Married

Medical History  Past medical history: Menopause  Past medications or drugs:  June 1997:  Premarin: treatment of moderato-to-severe vasomotor symptoms associated with menopause. No dental implications.  Provera: estrogen replacement in postmenopausal women. Provera may predispose the patient to gingival bleeding.  May 2003:  Advil: inflammatory diseases and rheumatoid disorders, mild-to-moderate pain, fever. No dental implications, but Advil may counteract the effect of baby aspirin and hinder its benefits as a preventive cardiovascular medication.

Family History  Heart disease  Diabetes  Cancer

General Health Excellent

Review of systems  Neurological: None  Psychological: None  Functional: None  Respiratory: None  Cardiovascular: None  Dermatological: None  Gastrointestinal: None  Sexual: None  Hematological: None  Endocrine: None  Immunological: None

Current medications  Aspirin 81 mg, (a.k.a. baby aspirin), 1 tablet/day.  Implications: Aspirin is a blood thinner.  Dental concerns: There may be excess bleeding during dental procedures, such as scaling and root planings.

Baseline vitals  First visit: BP: 124/80 P: 60 R: 14  Second visit: BP: 114/80 P: 52 R: 14  Third visit: BP: 118/80 P: 55 R: 14

ASA status : II  Rationale: Patient takes baby aspirin daily as a preventive measure.

Dental history  Last dental exam: 8/2008  Last dental hygiene care: 10/2008  Last FMX: 10/2006  Dental Hygiene intervals every six months.  Third molars extracted at age 23.  Orthodontic treatment at age 26.  Molar # 18 extracted in June Failed root canal treatment.  Tooth # 18 replaced with an implant in  Patient has been a patient of record at UCLA since  Patient has had most of her dental work done at UCLA.

Present status  Patient admits to grinding her teeth at night.  Patient wears a hard acrylic night guard.  Patient is aware of severe gingival recession in localized areas.

Clinical examination (pre-treatment)  Symmetry: WNL  Skin: WNL  Lymph nodes: WNL  Trachea: WNL  Thyroid: WNL  TMJ: WNL  Tonsils: WNL Extraoral findings

Clinical examination (pre-treatment) Intra-oral findings  Lips: WNL  Labial/buccal mucosa: Bilateral linia alba and bite marks on left side buccal mucosa.  Vestibules: WNL  Mucobuccal folds: WNL  Frena: WNL  Alveolar bone: WNL  Hard palate: WNL  Soft palate: WNL  Tongue: WNL  Floor of the mouth: WNL  Salivary glands: WNL  Tonsils: WNL  Occlusion: Unclassified clusion.  Anterior bite: 2mm overbite, over jet from 2-6mm.  Maximum opening : 52mm.  Attrition: Normal wear.  Erosion: None  Abfraction: None

Intraoral findings  Linia alba  Bite marks

Gingival description  Maxillary attached: pink, firm, stippled with moderate generalized recession areas of 1- 2mm.  Maxillary free: pink, firm, scalloped, smooth.  Mandibular attached: pink, firm, stippled with mild generalized and severe localized recession.  Mandibular free: pink, firm, scalloped, smooth.

Baseline plaque  PFI: 35%  PI: 65%  MBI: 9%

Baseline periodontal record  Pocket depth: Generalized 2-3. Localized 4 on teeth # 4,14,15,31.  BOP: #3 B, #3 DL, #14 Ml, #29 L.  Mobility: None  Furcations: None  Recession: Generalized 1-2 mm with severe areas up to 5mm on buccal surface of teeth #19 and 30.

Description of calculus LtM 3

Perpetuating factors  Restorations: Patient has several crowns in her mouth. Most of them fit well; nonetheless, they are a contributing factor to plaque accumulation.  Occlusion: Patient presents with problematic occlusion.  Hormonal activity: Hormonal fluctuation years ago may have contributed to systemic gingival inflammation and recession.

Etiology Plaque

Radiographic interpretation  The bone level is at about 3-4 mm below the CEJ in a horizontal line, which can be interpreted as generalized moderate chronic periodontitis.

Periodontal diagnosis (AAP) Generalized Moderate Chronic Periodontitis with Localized Severe Chronic Periodontitis

Oral hygiene evaluation (pre-treatment)  Patient’s Skill Level: Fair  Patient’s Knowledge and awareness of dental and periodontal disease: Fair  Objectives developed during OHI: Better plaque control.  Oral Hygiene Instruction: a) Flossing. b) Modified Bass and Roll brushing technique. c) Interproximal Brushing.

Caries examination Existing caries: None Existing restorations: Tooth # 2. PFM Tooth # 3. MOD composite filling Tooth # 4. PFM Tooth # 5. PFM Tooth # 13. MO alloy filling Tooth # 15. PFM Tooth # 18. Implant and PFM Tooth # 19. PFM Tooth # 20. DO alloy filling Tooth # 29. PFM Tooth # 30. PFM Tooth # 31. PFM

Radiographic evaluation (for caries and restoration needs)  No caries evident. No need for restorations, except smoothing distal surface of interproximal filling on tooth # 20.

Nutritional analysis  Patient filled out a 3-day food diary  I prepared a dietary My Pyramid.gov  A carbohydrate intake analysis was made based on the 3-day food diary  A nutritional counseling was done on the last appointment stressing the importance of proteins and milk products for a healthy diet

Fluoride analysis  Current usage of fluoride:  Patient uses Crest Pro Health daily, which contains 0.454% Stanous Fluoride  Patient cooks with tap water  Patient drinks tap water  Patient lives in the Beverly Hills area where the water has a fluoride concentration of 0.8 ppm.  I recommended fluoride varnish, but patient was not interested.

Dental Hygiene treatment plan  Appointment 1: RMH, Vitals, EO & IO, Probing, PFI, BI, OHI, Gather data.  Appointment 2: RMH, Vitals, EO & IO, Spot probing, Full Mouth Scaling, Selective Polishing.  Appointment 3: RMH, Vitals, EO & IO, Probing, PFI, BI, OHI, Gather data, Re-asses oral health and discuss nutritional analysis in order to make recommendations  Re-care: Every 6 months.

Post-treatment status  Patient compliance: Excellent  PI: 11%  MBI: 0%  BOP: 1%

References  Banihashemrad S, Fatemi K, Najafi M (2008). Effects of Smocking on Gingival Recession. Dental Research Journal. Retrieved May 10, 2009 from:  Remya V, Kishore K, Sabitha S, Arun DV (2008). Free gingival graft in the treatment of class III gingival recession. Indian Journal of Dental Research. Retrieved May 10, 2009 from _ pdfhttp:// _ pdf  Moawia M, Kassab and Robert E, Cohen (2008). The etiology and prevalence of gingival recession. The Journal of the American Dental Association. Retrieved may 10, 2009 from