Demographics

The patient is a 48 year old African American male. He is a heavy case and has Periodontitis Stage III Grade B.

Assessment 

The purpose of his visit is for an oral health examination and teeth cleaning. Patients presented with High Blood Pressure and the vitals were 143/92 with a pulse of 78. He is ASA II due to diabetes(Diabetic type II) and high blood pressure. Patient is taking 1000mg of Metformin, 100mg of Januvia, 25mg of Jardiance and 100mg of Arcabose. The patient reported self care is the following, uses a manual toothbrush with soft bristles, brushes twice a day, no floss, no oral rinse, and does not use a tongue cleaner. His last visit to the dentist was 5 years ago in 2017 and had a radiograph done in 2017 as well.

What is Diabetes?

Diabetes has two types, the first one is called type 1, and the second is called type 2. There is also a “prediabetes” but this usually presents no symptoms. In this case, the patient had type 2 diabetes. Type 2 diabetes is when it’s considered “insulin resistant”, which results in elevated levels of glucose in the blood. It usually occurs in adulthood and the risk factors include age, obesity, and lack of physical activity. It also slowly progresses over time and is frequently undiagnosed.

Condition Impact on Oral Health

Diabetes has a bi-directional relationship with Periodontitis. It increases the risk for severe periodontal disease by more than 2 to 4 times than the average person. With severe periodontitis, this can increase hyperglycemia and lead to diabetes complications, hence why it’s said to have a “bi-directional relationship.” So, having diabetes controlled is the best case scenario to help maintain excellent oral health with this condition.

Oral Pathology

In the extra oral findings, the patient was within normal limits. Intra oral presented bilateral linea alba, mandibular bilateral tori, and mucosa trauma due to cheek biting.

Dentition

Patient had generalized attrition and Abfraction. The class of occlusion was class II, bilaterally. Overjet was 2mm and overbite was 10%.

Periodontal Findings

The gingiva presented generalized diffused red, enlarged, inflamed, and soft gingiva with bleeding upon probing and exploring. The average probing depth was 4-5mm with localized 5-8mm on posterior teeth.

Radiographic Findings

Patient was exposed FMS, and radiographic findings show generalized calculus with >15% bone less.

Treatment Plan

The patient’s diagnosis was a heavy case with Periodontitis Stage III, Grade B. After educating the patient about how his condition impacts his oral health and the risks, recommendations for listerine ultra clean floss, a waterpik, tongue cleaner, a powered toothbrush, and gum detoxify deep clean toothpaste. Also, to maintain a close relationship between his medical professionals and dental professionals to help maintain proper oral care for her condition.