luis moreno & gita ansari. patient’s name: grover holland sex: male age: 36 ethnicity:...
TRANSCRIPT
PERIO PROJECTLuis Moreno
&Gita Ansari
General information
Patient’s name: Grover Holland Sex: Male Age: 36
Ethnicity: Caucasian
Profession: Registered Nurse
Marital status: Partnered
Medical History
HIV positive since 1990.
Suffers from depression
Severe dental phobia
Allergic to sulfa drugs
Past history
All childhood immunizations High fever as a child Recurrent headaches Recurrent backaches Urinary infection Other unspecified STDs.
Medications and health status
Atripla: antiretroviral drug for HIV infection
Pristiq Desvenlafaxin: NSRI drug for depression
Last medical exam: Jan/12/2010 CD4 count: 540 Viral load: undetectable
Treatment plan
4 quadrants of Root planings Tooth #1 surgical extraction Tooth #2 RCT, build up and PFM Tooth #14 DO composite filling Tooth #15 DO composite filling Tooth # 19 B composite filling Tooth # 30 MO composite filling Perio consultation
First appointmentAssessment only
BP: 130/90 Pulse: 74 Respiration: 14 ASA: II Alginate impressions Intraoral photos OHI
Oral assessment
Extraoral: WNL Intraoral: WNL Salivary flow: adequate PI: 26% MBI: 90% Calculus: Meduim-heavy Periodontal probings: generalized 2-4 and
localized 5-7. AAP: Generalized moderate chronic perio.
Gingival description
Color: generalized coral attached gingiva. Apparent red free gingival margin due to LGE.
Contour: generalized soft, spongy, hemorrhagic and edematous
Consistency: generalized bulbous, swollen
Texture: generalized glossy, smooth and shiny
Alveolar mucosa: WNL Tongue: WNL
Occlusal clasification
Mesognathic profile End to end bite on right posterior teeth. Edge to edge on anterior teeth. Cross bite on tooth #10 and all left side
posteriors. No TMD present . No deflexion or deviation. No myalgia at the time of evaluation.
Radiographs
Study models
Study models
Treatment
Second appointment
BP: 124/78 P: 80 R: 14 Sc/Rp LLQ &ULQ
with anesthesia.
Third appointment BP: 128/82 P: 77 R: 16 Sc/Rp URQ &LRQ
with anesthesia.
Treatment
Fourth appointment BP: 124/80 P: 60 R: 14 MBI 48% Plaque index 10% Intraoral
photographs OHI Nutritional
counseling.
Research: Highly active
antiretroviral therapy.