The patient is a 20-year-old Hispanic male. The patient is classified as ASA II due to having prediabetes type 2. The patient’s hb1ac is 5.8 from his recent medical check-up. The patient mentioned that his physician told him to stop taking his medication and recommended a healthy diet and exercise as a treatment plan. The patient doesn’t have any allergies, his blood pressure came out in the normal range, and he isn’t on medication.
The patient doesn’t drink, smoke or use drugs. For his oral hygiene, the patient mentioned he uses a medium bristle manual toothbrush with horizontal method and brushes his teeth once a day. The patient doesn’t floss and uses mouth wash 2 times a day.
Upon the oral exam, the notable findings were bilateral linea alba, fissure tongue, geographic tongue, and halitosis. Patient didn’t have any signs of cavity and no missing teeth. The patient’s gingival was severely inflamed, bleeding spontaneously, and there was redness on the gingival margin. I took HBW
and from the radiograph no signs of caries or bone loss. However, radiographic calculus was found. The patient was classified as heavy.
For home instruction, the patient was taught the Modified Bass method especially focusing on gingival margin. Scaled Q1 only due to tenacious calculus. Pain management was not needed. Due to his condition, I make sure my patient had eaten before all the appointments and if he didn’t, I offered water and a protein bar.
Revisit 2: The patient came back and mentioned that he sees less bleeding during his oral hygiene. However, he still brushes his teeth once a day. For home instruction, the patient was taught flossing. However, the patient was having difficulty using floss threader, so I recommended handle floss. Scaled
Q2 and 4. Rescaled Q1 due to residue calculus and new build-up No pain management was used.
Revisit 3: The patient’s gingival was less inflamed, and more firm since last visit. For home instruction alcohol free mouthwash was recommended. I had rescaled Q1,2, and 3 due to new build ups and scaled Q3 and applied 5% varnish. After all three visits I recommended rinses with warm salt water to prevent inflammation. I also recommend he get another professional cleaning in 3 months due to his medical condition and fast calculus build up.
