Initial visit: The patient is a 29-year-old Caucasian male. The patient is classified as ASA II due to having asthma, being allergic to crustaceans, and high blood pressure stage 1. The patient mentioned his asthma is well controlled and only uses his inhaler at night. Last time he had an asthma attack was several years ago. The patient also mentioned taking OTC Sudafed (pseudoephedrine) once a month during the winter to help with congestion. Due to his condition I asked him to bring his inhaler to every appointment.
The patient’s social life: he drinks 4 glasses of alcohol every 3 days and he consumes edible marijuana but doesn’t smoke.
Upon extra-oral inspection, bilateral crepitation on the TMJ was noted and solar lentigo around the neck. Patient reports there is no pain or discomfort on the TMJ and he does see a dermatologist every year. Intra-oral exam, the notable findings were redness on uvula, bilateral linea alba, crack on commissure of the lips due to dry lips, small trauma on the hard palate near tooth #8 from bagel he had
recently, bilateral mandibular tori, and macule on upper/light lips. Other findings lots of restoration and suspicious area on #20-O. The patient wanted to take x-rays in his primary dental office, so no x-rays was taken in the clinic.
The patient was classified as periodontitis stage II, grade B due to his periodontal charting. Gingival pocket deep is generalized 4-5mm on posterior buccal and lingual and anterior are more 1-3mm. There are lots of recessions on lower anterior and furcation class I on #18 and #31 buccal. The patient was classified as a heavy case with generalized subgingival calculus.
For home instruction, the patient was taught flossing with floss threader. Scaled Q1 only due to tenacious calculus. Pain management was not needed. I made sure to check on my patient during cleaning to check that he was comfortable and used high and low speed suction to remove aerosol and moisture that could trigger his asthma.
Revisit 2: The patient came back and mentioned that he sees less bleeding during his oral hygiene. For home instruction, the patient was taught the correct way to use an electronic toothbrush. The patient used to use his electronic toothbrush the same way he would a manual toothbrush, with horizontal motion, which was causing damage to his gingival. Scaled Q2 and 3, and no pain management was used. Referral form was given for suspicious area on #20-O.
Revisit 3: The patient’s gingival was less inflamed since last visit. Before any assessment we did CAMBRA (Caries management by risk assessment) so the patient would be aware of what would qualify him as “high-risk caries”. For home instruction I recommended a tongue scraper. After I scaled Q4 and applied
5% varnish. After all three visits I recommended he rinse with warm salt water to mitigate his inflammation. I also recommend that he should get a professional cleaning once every 3 months due to his periodontal disease and high caries-risk.
