MEDICAL HISTORY:
24 years old, male Hispanic, Heavy/ type II BP. 115/64. Pulse= 63. Patient has no history of smoking cigarettes. Did not have any systemic conditions, and is not taking any prescribed medications or OTC.
ORAL CANCER SCREENING:
During extra oral exam no significant findings and intraoral examination bilateral traumatic cheek biting was found.
PERIODONTAL SCREENING:
Patient presented generalized moderate papillary and marginal inflammation, most prominent on the posterior teeth and lower direct lingual incisors. Generalized probing depth of 4-6mm, and localized 7mm #14-BM. Patient presented localized areas of attrition on teeth # 24, # 25. Patient also presented heavy bleeding upon probing. Patient present localized vertical bone loss and generalized horizontal bone loss. Generalized clinical attachment loss on lower lingals.
CALCULUS:
Pt. was heavy, he presented generalized heavy sub/supra gingival calculus accumulation and light staining. His initial plaque score was poor. The most plaque accumulation was noted interproximally. I started using a Cavitron but, because he was too sensitive I had to administer local infiltration anesthesia. After that my patient was comfortable and he allowed me to work. After using the Cavitron,I used posterior and anterior Gracey instruments an sickles to finish the removal of deposits. I was able to complete my patient in three visits due to the heavy deposits.
TREATMENT MANAGEMENT
The treatment plan for the first visit was to teach the patient home care (the appropriate flossing technique), scaling the LL using hand instrumentation and Cavitron. On the second visit: taught the patient OHI,(modified Bass brushing technique),and I reviewed the flossing technique again because when I explored the areas previously scaled there was a lot of plaque accumulation. Patient stated that he was not flossing, as I had taught him previously. So I reinforced it again in that visit. I also recommended him to get an electric toothbrush. Plaque score was poor again. I was really disappointed, but I did my best to teach him again in that visit. I scaled the UL, LR quadrants using hand instrumentation, I also lavaged the LL that was previously done. By the third visit, I was really happy with my patient. Patient purchased a oral B electric tooth ( I had previously recommended ), he brought it with him to clinic that day. He really complied with the home care flossing and brushing because when I explored areas previously scaled it look pretty good and patient stated that he was not bleeding when he brushes his teeth. I also confirmed that bleeding had decreased tremendously when I explored areas previously scaled. His gums had adapted well, and he responded favorable to the treatment , selective polishing, and applied 5% sodium varnish fluoride treatment. I was really happy with the last result and the change that I could see in his gums. I also made him understand the importance of flossing and brushing correctly to keep a healthy mouth.
Referral was given to patient for further evaluation for suspicious caries lesion on teeth#’s 14,18,19,30,and # 31 class I.
After three months, patient came back to clinic, I was really content with his homecare. He became a medium sub- gingival calculus deposit minimal bleeding upon probing also probing depth was reduced to 2mm in a few sites.
Patient stated that he had followed up with the referral from the previous visit, he had already scheduled an appointment to restore the caries lesions that were found.
