1. Periodontal Case Study Project
Dental Hygiene Clinical Practice II

2. 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

3. 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)

4. Intra Oral Photos

5. Intra Oral Photos

6. Intra Oral Photos

7. Dental Chart

8. Periodontal Charting

9. Periodontal Evaluation

10. 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

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

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

13. Radiographs
Generalized slight bone loss

14. Radiographs

15. Radiographs

16. Radiographs

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

18. 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

19. 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.

20. Treatment Plan

21. Re-evaluation

22. 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.