DEH 23 Periodontal Case

Natalie Buzard

Riverside Community College

Patient Profile

32 year old, married white male

Chief Complaint- “to get my teeth cleaned.”

Dental History- Ortho- 1990-1992 No current appliances Grinds at night-no pain Cleaning & DDS-7/07 FMX 11/07 at RCC

Medical History Childhood Vaccine- 6-7 Hep. B-1996, no titer Outpatient shoulder

surgery- 7/07 Perkacet for 1 week for

pain after surgery 7/07 No other Medications

Clinical Findings- E&I exam

E: 6mm scar below lip, 15mm and 30mm scar on left side of neck- pt. visited dermatologist in 2006- abnormal collagen synthesis and extremely sensitive skin.

I: bilateral mandibular tori, palatal torus, bilateral linea alba, bilateral Fordyce granules, 2mm lip bite on labial mucosa between #8 & 9, keratinization on buccal mucosa at occlusal plane due to cheek biting.

Periodontal Evaluation

Assessments: Gingival Des: Free: Gen PSFS, Loc red,

edematous, bulbous and shiny Attach: Gen PFS Loc red on ant. Mandibular teeth

MBI: 12.5% BOP: 14.3% with gen. probing depth of 2-3, loc.

4 on M31 and M15 Recession- 1mm on Mobility: + on 6-11, 26-23 Fremitus: + on 7-9 Furcations: None RCC Calculus Code: Light/Medium

Radiographic Findings

Missing 1,16,17 &32 due to extraction at age 20.

Restor:3-C-DO, 14-A-O, 15-C-O, 19-C-O, 20-C-O, 21-C-O, 22-C-IL, 28-C-O, 29-C-O, 30-C-DO, 31C-MO

Tooth findings: cal on M15, dilaceration of mand. 1st molars

No abnormal osseous findings

Periodontal: trabecular pattern-

consistent throughout Lamina dura- present

and consistent throughout

PDL space- present and consistent throughout

Alveolar crest-1-2 mm below CEJ throughout

ADA and AAP

ADA: IAAP: Slight Gingivitis due to plaque and

calculusRCC Calculus Code: Light/mediumRationale for Selection: Compliant Patient

with Light/Medium Calculus

Dental Health Education

Patient flosses 1x per week

Taught “C” flossing technique

Encouraged patient to floss 3x per week

Patient brushes daily

Taught Bass Brushing Technique

Encourage pt. to brush at least 2x per day

Goals and Treatment Plan

Goals Reduce BOP to 7% Increase flossing to

3x/week

Treatment Plan Appt 1- Assessments,

DDS exam Appt 2- 2nd check-in,

OHI, PI, ULQ Appt 3, LLQ, URQ,

LRQ, selective polish-L#27&L#25, fluoride

Appt 4- 4 mos. recare

Periodontal Project- PicturesBefore After