Case Study II

ASA I. Patient a 59-year-old White male who presented with Type II periodontitis and heavy supragingival and subgingival calculus. His blood pressure was 132/71 and his pulse was 66. Patient is a nonsmoker and does not consume alcohol regularly. Patient does not have any allergies and does not take any medication. Patient has a Class I occlusion bilaterally with an overjet of 3mm, and overbite of 80%. Extra-oral examination revealed no significant findings. Intra-oral examination indicated inadequate knowledge about oral health. Patient had erosion present on teeth #19-21, and #28-29. Patient was exposed an FMS and PAN which revealed carious lesions present on teeth #14DO, #18O, #29D, and #30. Additionally, radiographs revealed impacted third molars. Patient was given a referral to see a dentist and an oral surgeon for restorative care and extraction of his third molars, respectively. Patient stated that when he was younger he would place vitamin C tablets on the buccal surfaces of his mandibular teeth. Over time, this constant acidic exposure resulted in tooth erosion. The patient was advised against this type of behavior and to minimize the intake of acidic foods and drinks. I recommended drinking from a straw when consuming acidic beverages and to rinse with water after acidic meals.


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dental charting