1. DH 290 Oral Case Study Fall 2015 Laci Page
George Allen
DH 290 Oral Case Study Fall 2015
Laci Page

2. Patient Vitals Blood Pressure = 142/98 mmHg, right arm
Pulse = 84 BPM, right arm, weak and thready
Respirations = 14 RPM, odor free, easy, steady
Temperature = 97.8 F Temporal
Tobacco use- None

3. Patient History Mr. Allen is a 55 year old Caucasian male.
He is married with three kids and four grandchildren.
Work: Mr. Allen drives a large 18 wheeler for local business in Carthage Missouri. Driving this truck has lead to back pain for Mr. Allen recently.
Mr. Allen’s last dental visit was August of 2014 for a general exam.
Mr. Allen noted that his dentist plans on doing more extensive dental work, but that he will first need to get a “deep cleaning”, or SRP. Mr. Allen’s insurance would not pay for the treatment, so he came to our clinic at MSSU.
Patient shared that he needed a “deep cleaning” at the time of his last cleaning, which was about 20 years ago, but only got a regular prophy appointment.

4. Patient History
Mr. Page has had a history of high blood pressure, though undiagnosed and back pain.
Hospitalized for appendix removal in the 1980’s
No allergies
Medications: Mr. Page is taking 2 Aleve twice daily for swelling in lower back, Advil once daily as needed and a Bayer Aspirin (children’s strength) when remembered as preventative heart care.
Drinking: None
This patient indicated no significant family history.

5. Medical History Form

6. Intraoral Photographs

7. Severe attrition on Maxillary Anteriors

8. Radiographs – 20FMX
*Due to patient’s severe gagging, the 20fmx was stopped and a panoramic was taken instead.

9. Radiographs – Panoramic

10. Dental Charting
* This dental charting was completed at a time when our computer system did not indicate charted conditions on the teeth images.

11. Periodontal Charting

12. Perio Charting- Re-Eval Sextant 1

13. Oral Findings Generalized yellow staining
Severe attrition, especially on maxillary anteriors due to grinding
Bilateral linea alba
Jaw deviated to the right upon opening
Callused bump or scar at midline of bottom lip where maxillary anteriors occlude over the lip
Active periodontal disease due to, heavy calculus, 4,5 and some 6mm pockets, and bone loss
Gingival statement: Generalized mild marginal inflammation with localized moderate inflammation around upper and lower anteriors with bleeding on probing.

14. Process of Care Treatment Form

15. Microscope Bacterial Findings: Phase Microscope
Filamentous, Masses of Cocci and Shortrods, Fusabacteria, and Leukocytes.
Filamentous, Masses of Cocci and Shortrods.
Masses of Cocci