Re-care visit
Medical History: 51 yr old African-American female with Stage III Grade B periodontitis. The patient has anemia, is being evaluated for a benign thyroid cyst, and has undergone breast cancer masctomy (right side) on July 2020. She takes 20mg of Tamoxifen nightly prescribed by her oncologist along with her chemotherapy treatment. Tamoxifen side effects: hot flashes, nausea, fluid retention, skin changes. She reports to experience night sweats. Patient receives intravenous medication 2x/year for anemia, as well as OTC vitamin C,D, and probiotics.
Dental History: She wears a mouth guard at night due to grinding, has xerostomia, and has hypersensitivity. Patient uses a powered toothbrush with Sensodyne toothpaste 2x/day. She also uses Biotene mouthwash for xerostomia in the morning and ACT mouthwash at night.
While doing a head and neck exam, the patient explained that she has a pending appointment for surgery to get her thyroid cyst removed, however her chemotherapy is a priority in the meantime. TMJ evaluation showed that she has a stiff lower jaw. Intra-oral findings included: bilateral linea alba due to cheek biting; petechia and pigmentation along the hard palate in which patient reports to consume hot beverages often, enlarged tonsils along with a tonsil stone on the right side; coated, fissured, and pigmented tongue.
Dental charting: Suspicious carious lesion was detected on #2D, generalized attrition, and erosion. Bilateral class III tendency, 1-3mm overjet, along with 5% overbite. Fracture on the incisal edge of #8 and #9. Patient also has composite and amalgam restorations. During dental charting patient reported that #30 was bothersome even after previous DDS evaluation from her other clinic.
Periodontal Findings:
Since her last dental hygiene visit, furcation of #31L has gone up, increase in both bleeding and probe readings of up to 5mm around mandibular molars.
Gingival Statement: Generalized pigmentation, recession, firm, and non-stippled gingiva with bleeding upon probing. According to her periodontal findings, she was categorized as Stage III Grade B periodontitis.
Moderate subgingival calculus was found on the proximal surfaces of the right quadrants.
On the first visit, assessments were completed and treatment plan was reviewed and signed. Disclosing solution showed most plaque on premolars of right quadrants. Visit 1 plaque index score: .5- Good. Proxy-brush was shown for diastema area. Patient was told to begin home care regimen by brushing right side with her powered toothbrush. Quadrant 1 was scaled. The patient was recommended to purchase reusable metal straws due to her high preference of acidic beverages and hot teas. She was also taught the impact of frequently consuming these beverages on the enamel of dentition. Listerine Total Care was recommended for protection against caries. A referral for suspicious carious lesion on #2D was given.
On the second visit, OHI was reviewed, plaque index score improved (.3), and less bleeding was noted. Quadrants 2-4 were scaled, engine polishing was done with fine prophy paste. Lastly 5% NaFl varnish was applied for high caries risk. The patient was recommended Oasis products for xerostomia. 3 month re-care was recommended to this patient.
