Medical/Social/Dental History
A 40-year-old Hispanic woman age 40 presents to the clinic with Bipolar disorder, Attention-deficit/hyperactivity disorder (ADHD), insomnia and suffers from binge eating. This patient was prescribed to take 150mg of Trazadone which is an antidepressant medication used for insomnia, 75mg of Lamotrigine for bipolar disorder, and 70 mg of Vyvanse for ADHD and binge eating. In addition to 60mg of Buspirone for anxiety and 150 mg of Wellbutrinxl for depression. The patient stated that she takes these medications daily and reports suffering from dry mouth, which is due to the use of medications. She also has a latex allergy and was hospitalized two years ago after having surgery done on her foot. Her last dental cleaning and radiographs were in January of 2020. This patient is a nonsmoker and does not consume any alcoholic beverages. After interviewing the patient about her current homecare, she reports brushing with a soft manual toothbrush using Prevident toothpaste, flosses with traditional string floss, and rinsing with non-alcohol-containing Listerine once a day
Assessments/Clinical Findings
Mild xerostomia, bilateral mandibular tori, and linea alba were detected after an extra/intraoral exam was conducted. Mild localized erosion along with suspicious lesions was found on the occlusal of the molars and the mesial of tooth# 3. After all assessments were completed I was able to determine her periodontal status, draft a treatment plan, and develop an individualized home care plan to cater to the needs of this patient. The patient gingival contained marginal redness, inflammation, and localized rolled gingiva on the facial aspect of the mandibular anterior teeth. There was generalized 2-4mm PD with localized 5-6mm PD along the posterior teeth, no clinical attachment loss, and light bleed upon probing. Moderate calculus deposits were present above and below the gingiva along the lingual aspect of the mandibular teeth and mandibular molars.
Dental Hygiene Care Plan
Following the completion of assessments, the periodontal status was determined to be generalized moderate gingivitis. My patient was aware of all findings and 4 horizontal bitewing were taken to confirm the suspicious lesions. I advised that the patient return to the clinic for one more additional appointment due to her intense medical history and for reevaluation of the gum tissue. Topical 20% benzocaine was put into the treatment plan for pain management along with 5% sodium fluoride varnish. Topical was initially used during periodontal probing due to slight dental anxiety during the first appointment but was no longer needed throughout her treatment. The patient was also given a referral for caries evaluation and encouraged to follow up with a dentist.
Individualized Home Care regimen
After discussing her diet and binge eating habits were full of carbohydrates and excess sugar I advised that she start small by replacing Lay’s potato chips with some baby carrots. We agreed that she should continue using Prevident toothpaste, and add Biotene mouth rinse into her regimen to reduce dry mouth and the accumulation of caries. I made corrections patient’s use of string floss and introduced her to the tuft-ended brush to control calculus buildup on the lingual aspect of the teeth. Overall my patient was extremely pleased with her cleaning and agreed to return to the dental clinic at NYCCT for her 4-month re-care appointment which was suggested due to her being at high risk for caries.
