1. Luis F. Moreno

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

3. 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.

4. Family History  Heart disease  Diabetes  Cancer

5. General Health Excellent

6. 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

7. 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.

8. 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

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

10. 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 2005. Failed root canal treatment.  Tooth # 18 replaced with an implant in 2007.  Patient has been a patient of record at UCLA since 1973.  Patient has had most of her dental work done at UCLA.

11. 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.

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

13. 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

14. Intraoral findings  Linia alba  Bite marks

15. 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.

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

17. 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.

18. Description of calculus LtM 3

19. 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 10- 12 years ago may have contributed to systemic gingival inflammation and recession.

20. Etiology Plaque

21. 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.

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

23. 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.

24. 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

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

27. Nutritional analysis  Patient filled out a 3-day food diary  I prepared a dietary analysis @ 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

28. 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.

29. 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.

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

31. References  Banihashemrad S, Fatemi K, Najafi M (2008). Effects of Smocking on Gingival Recession. Dental Research Journal. Retrieved May 10, 2009 from: http://journals.mui.ac.ir/drj/article/viewFile/2882/1107 http://journals.mui.ac.ir/drj/article/viewFile/2882/1107  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 http://www.ijdr.in/temp/IndianJDentRes193247- 5866461_161744.pdfhttp://www.ijdr.in/temp/IndianJDentRes193247- 5866461_161744.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 http://jada.ada.org/cgi/reprint/134/2/220.pdfhttp://jada.ada.org/cgi/reprint/134/2/220.pdf