1. Periodontal Case Study Project
Dental Hygiene Clinic II
Cassandra Ligor

2. Patient Profile Brushes with soft tooth brush 2xd Flosses 1xd
Health History :
Dental History
45 year old Caucasian female.
Non – contributory health history
Job related stress
No contraindications to TX
ASA I
Vital signs WNL
No dental anxiety
Routine 6 month re-care
Brushes with soft tooth brush 2xd
Flosses 1xd
Uses night guard
Grinds teeth

3. EXTRA ORAL AND INTRA ORAL FINDINGS
Bilateral linea alba on the buccal mucosa
Slight tori on the palate
Petichiae on the orifice of the right tonsil
Slight scalloped tongue and a short lingual frena.
Attrition on teeth and 9 had chips on the incisal edge
Class I occlusion.
70 % overbite and 3mm over jet
Caries risk factors is moderate due to previous restorations and eats candy.
No oral cancer risks patient never smoked.
Oral habits are grinding at night and patient wears a night guard

4. Intra Oral Photos

5. Intra Oral Photos

6. Intra Oral Photos

7. Intra Oral Photos

8. Intra Oral Photos

9. Intra Oral Photos

10. Dental Chart

11. Perio Chart

12. Assessment findings BOP on 4, 30 , and 31
Plaque index was 16% on initial visit
Supragingival calculus on 2,3,14,15,23-26
Subgingival on 2,3,13,14,15,29,27-23,18 and 18
Soft deposit on buccal and lingual of maxillary and mandibular premolars and molars.
4,5,12,13,18 faulty restorations
Carious lesion on 3,18 and 19
Localized recession on buccal of 19, 20 and 21

13. Gingival Description
Generalized pink, normal, knifelike margins, stippled tissue, with localized recession on teeth number 19, 20 and 21.

14. Factors Stress- work related Hormones Faulty restorations
Risk factors
Contributory factors
Stress- work related
Hormones
Faulty restorations
Position of teeth/malocclusion
Occlusal discrepancies
Parafunctional habits-grinding clenching
Calculus

15. Radiographs

16. Radiographs

17. Radiographs
Slight/moderate horizontal bone loss on teeth number 4, 5 and 6. and slight/moderate horizontal bone loss on tooth number 31.

18. Radiographs
18 and 19 have slight/moderate vertical bone loss and there is slight triangulation throughout these x- rays.

19. Periodontal Diagnosis
Generalized slight inactive chronic periodontitis, with localized active chronic periodontitis on # 4,30,31
AAP II

20. Treatment Plan

21. Procedures First visit completed indices and assessments.
Second visit: review and update medical history and cursory exams. Biofilm index and reviewed self care and flossing techniques. Started debridement with power driven scaler.
Third visit: review and update medical history and cursory exams. Biofilm index improved by 5%. Debridement with the power driven scaler, toothbrush, and fluoride trays.

22. Summary
This patient was very compliant and visits the dentist regularly, so the calculus buildup wasn’t very severe. Scaling with the ultrasonic went very well although the patient experienced sensitivity on the upper left side, and lower right side. Most of the recession was on the left side of the mouth. Especially on the mandibular pre-molars. Although this patient has normal healthy gingiva, the AAP case type is II due to the amount of recession present, which was why the CAL’s were between After reviewing the x-rays there is not a lot of bone loss present, only slight on a few teeth, horizontal and vertical. This patient has taught me how important it is to look at the details when determining the case type and periodontal diagnosis. This was my first patient and I realize how the perio chart could use adjusting. For example the Gm’s on the posterior are 0 and since the papillae are not blunted it should be plus 1 or even 2. the dental chart also needs to be changed, with some of the watches on the restorations. This project really helped me to evaluate my work and see how much I have improved in perio and other dental hygiene services.