Assessment: A 36 years old, Hispanic female patient visited to get a dental cleaning. Blood pressure was taken – 107/65, corresponds to normal. First, reviewed the patient’s medical, social, dental history through patient interview. Patient reported she has no seasonal allergies but was hospitalized for Multiple Sclerosis (MS) in Feb 2022. Patient denies any medications. Patient reported she smokes medical marijuana through a vape every night for pain management. ASA: 3 due to MS. Patient stated that her last physical 03/2023. Patient stated last dental visit was in July 2023 for dental implant consultation where an FMS 1 was taken. Last dental hygiene services were done in NYCCT in 10/2023. Patient stated that she is overdue for a cleaning. Patient reported she uses an electric toothbrush, brushes once a day, using Colgate toothpaste. Patient reported that she uses Waterpik and rinses with Listerine oral rinse occasionally.

An Objective finding was proceeded. During the extraoral and intraoral examination, Submandibular lymph nodes present (asymptomatic). While opening and closing, TMJ locks. Patient reported she feels pain sometimes but knows how maneuver when jaw locks. Bilateral linea alba present. Maxillary torus present. Fordyce granules present bilaterally on commissure. White-coated scalloped tongue present.

Dental chart recorded and patient had bilateral class I occlusion, overjet 3mm, overbite 50%. Attrition present on upper and lower anterior teeth. Gingival statement was generalized red, inflamed, non-resilient, puffy, retractable, gingiva with localized rolled, bulbous gingiva on lower anterior linguals.

Perio charting was recorded. Generalized 2-4mm PD with localized 6-7 mm PD on some posterior teeth. Localized 3-4 mm CAL present on #31 and #19. No mobility was detected. Calculus was localized moderate subgingival calculus present on some posterior teeth and supragingival calculus confined to the lower anterior lingual surfaces. – case type decided as medium. Stain was light.

Diagnosis: Patient shared x-rays that were taken in another office. Based on radiographic evidence, perio status was diagnosed as generalized Stage III, Grade B. Caries risk was high/ CAMBRA done – recommended patient to visit dental regularly (at least every 3 months), floss between teeth in addition to waterpik due to past interproximal caries and possible active cares. Recommended xylitol gum for dry mouth.

**These x-rays were taken at another office in 08/2023.

Carious lesions present clinically on #9-DL, #13-D, and #16-O. Suspected recurrent decay present on #3-O, and #15-O. Calculus present. Radiographic bone loss greater than 15% noted in posterior region. No jawbone abnormalities present.

Plan: Completed all intake data/ assessment. Tx plan developed and discussed with patient and patient signed the consent. Radiographic/clinical findings were discussed with the patient. Discussed clinical findings and diagnosis of Periodontitis with patient.

Detailed Tx plan was:

  1. Visit 1 – complete assessments, discuss CAMBRA, discuss diagnosis, introduced OHI – flossing, apply topical Benzocaine 20%, scale all 4 quadrants, engine polish with coarse prophy paste, apply 5% sodium fluoride varnish.

Implementation:

Visit 1 – Vital signs were taken, and a BP of 107/65 and PR of 75 recorded. Medical and dental history taken and discussed. ASA III was designated based on MS. All assessments completed. Completed CAMBRA assessment to obtain caries risk and provided appropriate recommendations. Oral hygiene instructions were given – The patient was shown how to floss, and they were able to replicate the technique. Referral to General Dentist and Primary Physician was given. Scaled all 4 quadrants with ultrasonics and hand instrumentation. Engine polishing completed with coarse prophy paste. 5% Sodium fluoride varnish was applied, and post op instructions were given. Instructed patient to rinse with warm salt water if any discomfort; tomorrow continue with OHI given. Recare recommendations given and recare appointment/interval set at 3 months.

Continued Care Recommendations: Recare appointment/interval set at three months due to generalized Stage III, Grade B Periodontitis. Stressed the importance of following up on referrals given for suspected caries and periodontitis. Reviewed with the patient the significance of routine dental cleanings and maintaining proper oral hygiene at home to uphold optimal oral health. This will help with stabilizing the disease and not progress in the future.

The initial image displays the mandibular anterior lingual surfaces with substantial supragingival calculus confined to the teeth. The subsequent images, captured post-cleaning. In the third photo, #13-D exhibits a suspected caries that requires further evaluation. The patient was left satisfied with before and after results.

Document: All intake data/ assessment documented. Patient signed all documents and consent. Referral letter was given for evaluating suspicious caries and evaluating perio disease.

***The patient consented to the taking and sharing of pictures.