Demographics
Patient is T.B., 22 years old, Medium/ Type II.
Assessment
Patient has allergies to nuts and shellfish. She is advised to carry an Epi-pen but does not currently carry it on her. She has one at home but it is passed expiration. Patient is anemic. Took iron pills from the age of 7 to 13. She was then instructed by her doctor to stop taking the pills and control the anemia by dietary means. She has had no complications to date.
Vital signs were within normal limits, BP 93/66 and Pulse 79.
ASA II.
Patient is a Non-smoker.
No pre-medications required.
Oral Pathology
EOIO was within normal limits. No significant findings to report.
Dentition
Patient class of occlusion: Class 1. Overjet, 3mm. Overbite, 10%.
Attrition found on teeth #’s 7 and 10.
Suspected caries on teeth #’s 2,3,18,31, and 32.
Periodontal
Patient had probing depths of 1-5mm, periodontal type II.
Recession present on buccal aspect of lower right molars (#’s 30,31 and 32) and the facial aspect of tooth # 22.
Minimal bleeding upon probing.
Gingiva was generalized healthy, pink color with no inflammation.
Oral Hygiene
Patients initial plaque score was .8 (Fair).
Subgingival calculus present mostly on posteriors and supragingival calculus found on lingual aspect of mandibular anteriors.Patient was given oral hygiene instruction of flossing.
Radiographs
4 horizontal bitewings were exposed on this patient during her second visit. The radiographs showed presence of multiple carious lesions in the molar areas, which were noted clinically during dental charting. Also present on radiographs were areas of vertical bone loss around molars on the mandible, where deeper pocket depths were found clinically.
Treatment Management
On the patient’s initial visit all assessment was completed but I did not begin any scaling. On patient’s second appointment we began by doing a plaque score. Her score was a .8. I chose to instruct the patient on proper flossing technique. I then recommended and discussed a treatment plan for 4 quadrant scaling. We then exposed 4 HBW due to suspicious carious lesions. I then scaled entire 4 quadrants to completion. A topical anesthetic, Topex 20% benzocaine, was used on the lower right quadrant because the patient was feeling some discomfort. I then rubber cup polished with a fine grit paste and finished with a neutral sodium fluoride treatment for 5 minutes. I recommended a 6 month recall. Patient was referred to dentist for caries evaluation.
I believe the patient was motivated to improve home care because she was asking a lot of questions and took very well to my instruction and demonstrated the technique back to me very well. She seemed to be very concerned at the fact that she had some active areas of caries.
I recommended incorporating an oral rinse with fluoride as well as daily flossing and brushing.
I believe I chose an appropriate treatment and education plan for my patient.
Evaluation
Patient took very well to instructions and seemed to be generally concerned about her oral health. She seemed uneasy when she was told about the numerous suspected carious lesions and was anxious to go see a dentist.
The patient’s gingival tissue was consistently generalized healthy with a pink color.
The one change that was made to our treatment plan was the use of topical anesthetic (Topex 20 % benzocaine) during scaling of the lower right quadrant because she was experiencing some sensitivity.
Reflection
I believe I accomplished all I wanted with this patient both educational and mechanical. Again my problem was my time management. Ideally I would have got to scaling on the initial appointment, but I was extremely thorough with my medical history interview because the patient didn’t fill out the medical form to completion. A positive experience that I can take from this patient was that it was the first patient I had that I didn’t personally know. I felt that by the end of her treatment she trusted me and was very happy with the treatment rendered. I felt that this would test my personal and professional skills and I believe I was successful with both. The only negative was my time management as far as scaling, but faculty was happy with the way that I interviewed and pulled the information from the patient that she had not filled out or left out details about herself on her medical form.
