Assessment: An 86 year old caucasian male stopped by for his routine dental cleaning. Blood pressure was 164/86 pulse: 76 corresponds to hypertension stage 2 (patient was informed of findings). I reviewed the patients medical, social, and dental history through the patient interview and was able to obtain important information that is relevant to his case. His last physical annual medical checkup was on 11/21/2024. The patient stated that he had melanoma and prostate cancer in the last 5 years. He also had radiation therapy and is currently in remission. He is taking prescribed medications such as Aspirin 81mg, Atorvastatin 40mg, and Ramipril 10mg (all 1x a day). The patient is also taking OTC drugs such as Vitamin D3 and B-12. The patient has no allergies or side effects from these medications. He is a social drinker, he does not smoke or use any illicit drugs. His last dental checkup was in January 2025 for a routine dental cleaning. Patient uses soft manual TB 2x a day with vertical method brushing. He uses a proxy brush 1x a day and string floss 1x a day. The patient is ASA: 3 Due to having melanoma and prostate cancer in the last 5 years, high blood pressure and cholesterol as well as having been on radiation therapy.
An objective finding was proceeded. During the intra and extra oral examination the patient has red scab marks on the lower lip from razor blade when shaving. He had bilateral crepitus on the TMJ and bilateral swollen mandibular lymph nodes. Bilateral linea alba as well as bilateral submandibular tori was also present. The dental charting of this patient was that he had class 1 occlusion bilaterally. An overjet of 10mm and an overbite of less than 10%. Missing teeth included #8, #9, #11, #23 and #24. All teeth had crowns on them. There is an anterior bridge on the upper and lower jaw. The gingival statement was that the gingiva was pink, fit snuggly around the teeth, firm, and stippled. The GM meets the CEJ. The perio charting consisted of localized 4-6mm probing depths on the molar/premolar teeth. No mobility or recession was detected and there was slight BOP. There was localized subgingival calculus on 2M. The case type that was established was a light stage III grade B from radiographic evidence.
Diagnosis: After exposing a full mouth series (FMS), based on radiographic evidence there was generalized >33% horizontal bone loss. There was also calculus present radiographically on 2M. There were no suspicious carious lesions. Based on radiographic evidence the perio status was diagnosed as stage III grade B. According to CAMBRA – patient presents as a moderate risk because they had restorative dentistry in the last 2 years. Instructed the patient to use super floss on his upper and lower anterior bridge and to use the modified bass brushing technique to get the most benefits from his daily toothbrushing routine.
Plan: After completing all assessments and gathering relevant information, the treatment plan was developed and discussed with the patient who signed it off and gave consent. Radiographic and clinical findings were discussed with the patient in further detail. The treatment plan consisted of only 1 visit which included exposing a full mouth series (FMS) radiograph, OHI, CAMBRA, hand scaling and using the ultrasonic on the entire dentition to completion, engine polishing with fine paste. Patient denied Sodium Fluoride varnish 5%. A referral for a comprehensive dental evaluation was also given.
Implementation: As soon as the patient signed all consent forms and the treatment plan was discussed with him, I exposed a full mouth series radiograph to get a comprehensive review of all of his teeth. After we obtained the radiograph, I began to discuss with my patient in further detail about all my significant findings that I gathered from the radiograph. Since the patient denied PI that was not included in the treatment plan. I began to go over oral hygiene instruction (OHI). I taught him how to use the super floss on his upper and lower anterior bridge as well as flossing all the teeth and why this would be beneficial to his specific case. CAMBRA was also completed so that the accurate caries risk was determined and proper home care was being fulfilled. I began to hand scale and use the cavitron on each quadrant to completion. I engine polished with fine paste to remove additional staining. A referral was given for a comprehensive dental evaluation.
Evaluation: During the discussion about the patients radiographs and me introducing OHI, I carefully observed my patients understanding about what was being discussed. I evaluated my patient, by having him demonstrate how to use the super floss on his upper and lower anterior bridge. I also asked follow up questions to make sure he understood what bone loss meant and how it can negatively affect the outcomes of teeth if its not being taken care of as soon as possible. My patient had a clear understanding that periodontitis cannot be reversed and could only be prevented from getting worse by maintaining proper home care.
Documentation: All data and assessments have been documented. Patient signed all documents and consent forms.