Visit #1: N.S. 28 yr old female H/II localized III. Date of Service: 10/10/17
ASSESSMENT: Pt does not require any premedication.Vital signs all within normal limits. Pt has a history of polycystic ovary syndrome. Pt is not taking any medications.
ORAL PATHOLOGY: None, EOIO WNL.
DENTITION Patient had no attrition, erosion, abfraction or abrasion to note. No tooth abnormalities observed during assessment. No caries detected clinically or radiographically.
PERIODONTAL 1. Pt gingiva has melanin pigmentation. Stippling present. Rolled gingival margins noted in the molar areas. 2. Pt was found to be a type II localized type III. Probing depths of 1-6mm with moderate BUP. Bone loss evident on radiographs around first molars both maxillary and mandibular, classified as localized aggressive periodontitis. 3. Arestin would be appropriate for this patient in areas of deeper probing depths.
ORAL HYGIENE 1. Pt classified as Heavy case based on generalized heavy subgingival calculus, also evident on radiographs. 2. Methods used to assess the patient’s oral hygiene was conversation about her daily oral hygiene routine at home, and speaking about how often she has visited the dentist. This patient was not from this country and had never been to a dentist, so it was a great conversation to educate her on the importance of home care and regular scheduled check ups. 3. PI Score: .8
RADIOGRAPHS 1. FMS was exposed because the patient had generalized sensitivity on probing and had never had any type of dental radiograph done before. 2. The radiographs showed bone loss in multiple areas, mostly on first molars and calculus was evident on the radiographs as well.
3. Clinically we were not able to diagnose localized aggressive periodontitis because we did not have the radiographs. Once exposed we could classify the pt with localized aggressive periodontitis.
OTHER FINDINGS 1. Pt is a non smoker, and does not drink. 2. Pt had never been to a dentist so there was some dental anxiety, which subsided as we continued with our visits and as I continued to educate her as to why we were doing what we were doing.
TREATMENT MANAGEMENT during each visit:
VISIT 1: Discussed and recommended 4 quadrant scaling and exposing FMS. OHI tooth brushing with the modified bass brushing technique and the addition of an antiseptic mouth rinse. Teeth #’s 25,26 and 27 were scaled using hand instrumentation and ultrasonic. Pt was experiencing discomfort, so we discussed the use of local anesthetic for visit 2.
VISIT 2: Reassessed teeth 3’s 25-27. Exposed FMS. Dr. Ekelman administered 2 carpules of Lidocaine HCI 2% and Epi 1:100,000 via local infiltration on the LRQ. OHI flossing with waxed floss and discussed the use of floss holders. Scaled the LRQ using hand instrumentation and ultrasonic. Severe bleeding on the molar areas. Tx plan was modified to more sessions due to the severity of the pt’s condition.
VISIT 3: Pt stated that her “gums were a little sore.” Advised pt to take ibuprofen post visit if needed. Dr. Ekelman administered 1 carpule of Lidocaine HCI 2% and Epi 1:100,000 via local infiltration on the LRQ. Scaled the LRQ to completion using hand instrumentation and ultrasonic. Professor Spielman administered 1 carpule of Lidocaine HCI 2% and Epi 1:100,000 via local infiltration to the URQ. Scaled the URQ to completion using hand instrumentation and ultrasonic.
VISIT 4: Reassessed URQ and LRQ. Professor Fernandez administered 1 carpule of Lidocaine HCI 2% and Epi 1:100,000 via local infiltration to the LLQ. Removed residual calculus from URQ and LRQ. Scaled the LLQ to completion using hand instrumentation and ultrasonic. Professor Spielman administered 1 carpule of Lidocaine HCI 2% and Epi 1:100,000 via local infiltration to the ULQ. Scaled the ULQ to completion using hand instrumentation and ultrasonic. Rubber cup polish with fine grit paste and applied fluoride varnish. Post operative instructions given to pt. Patient placed on a 3 month recare.
2. For the deeper pockets and bleeding of the gingiva recommended a chemotherapeutic mouth rinse. During OHI the pt stated she did not like to put her hands in her mouth and that it was hard to reach her back teeth so we discussed the use of floss holders. Pt liked the floss picks and said they were easier to use.
3. Pt was given a referral for DDS for general check up and also to see a periodontist to address the localized aggressive periodontitis.
EVALUATION A. Pt seemed to respond well to the interventions of the past visits. She said that she has felt a difference between visits of the quadrants that were scaled and that we still needed to scale. She said they bled less and felt better. B. The pt seemed extremely interested in her oral health once I educated her on her current condition and what we would have to do as treatment to restore oral health. Having the radiographs and explaining the findings were good tools to educate the patient. C. The gingival tissue showed signs of healing as the sessions continued. Bleeding decreased dramatically and inflammation reduced.
STUDENT REFLECTION: Reflecting on my clinical treatment and faculty feedback I felt like this was mostly a positive experience for me. My strengths in this particular pt case was taking time to educate the patient and my clinical skills as far as calculus detection and removal. Faculty mentioned to me that this was a very difficult case and I think my time management and scaling skills were very good. I also appreciated that the patient needed more time with explaining what we were doing as english was not her first language. I believe that I made the pt very comfortable as she had never been to the dentist and had never been anesthetized. I talked her through step by step what we were doing and why we were doing it. I think this calmed her and made her more secure in my abilities to treat her.
I don’t believe I had any specific weakness in this case, but this particular case made me more knowledgeable of localized aggressive periodontitis. Having the experience of speaking with Dr. Ekelman and discussing in more detail the specifics of the disease helped me understand more about it as well as treatment.