Patient B:
Assessment/Diagnosis:
57 year old, hispanic, female presented for her semi-annual cleaning during April 2025. Last cleaning was done in September 2024, last dental radiographs were 4VBWs done in April 2024. Patient has no allergies. Takes Atorvastatin 40 mg for high cholesterol. Patient has GERD, but paused treatment with Famotidine in January 2025. Patient has arthritis which she treats with therapies. Patient is a non drinker, non smoker. She brushes twice a day alternating between a manual soft bristled brush and Oral B electric toothbrush. She uses a water flosser twice a day, uses Therabreath rinse and Sensodyne toothpaste.
Upon oral cancer screening, slight bilateral crepitus was noted to which the pt. mentioned feeling some discomfort when opening wide. Bilateral linea alba was also present. Pt. has a bilateral class II division 2 occlusion, 20% overbite and 6mm of overjet. Pts. gingiva presented pink and enlarged generalized. Papillae were enlarged generalized, margins were apical to the CEJ generalized and margins were localized rolled in the mandibular anterior teeth. No BOP or exudate. Pts. PDs were generalized between 1-3mm and generalized recession was present. Pt had generalized mild sub gingival calculus and supra gingival calculus. PI was 1 mainly on the linguals of the mandibular anterior teeth. No staining. Generalized mild attrition.
Planning:
It was determined we needed radiographs to check bone levels and to check for caries due to pt having periodontitis and being a moderate caries risk pt. It was also determined we needed to check her TMJ because of the feeling of discomfort upon opening wide. It was determined the pt. was a medium case value due to the generalized mild sub and supra gingival calculus present. She was also previously classified with periodontal disease as a stage 3 grade B, based on periodontal charting and radiographic bone loss. Her caries risk is moderate due to her having multiple existing restorations and not having a dental home. Fluoride varnish was recommended to prevent caries lesions and to relieve some sensitivity mainly on her exposed root surfaces. She was given a 3 month recare interval, due to her building up plaque very quickly and to maintain her periodontal disease from progressing any further.
Implementation:
4VBWs and PAN were exposed. The radiographs showed Localized calculus deposits on the left side of the mouth, beyond 33% of horizontal bone loss, no carious lesions and no PAPs on the PAN. Due to pt. sensitivity the cleaning was split into two separate visits and local anesthesia was administered each time. The first visit the pt. was taught how to use proxy brushes to clean embrasure spaces in the mandibular anterior teeth and QDs 1 and 4 were scaled to completion. The second visit the patient mentioned she attempted to use proxy brushes and will try to incorporate them into her daily routine. She did mention having had some sensitivity for a few hours after the initial appointment. During this visit she was taught how to brush correctly with the Oral B electric toothbrush, the use of electric toothbrush was encouraged over the use of the manual tooth brush due to her arthritis. QDs 2 and 3 were scaled to completion on this visit. Her teeth were polished and flouride varnish was applied.
Evaluation:
Upon returning to her second visit she mentioned how happy she was seeing the difference in the right and left side of her mouth. The right having no supra gingival calculus and her seeing spaces between her teeth, while on the left she saw the supra gingival calculus and didn’t have spaces between her teeth. The pt also expressed how she felt very comfortable with the local anesthesia and had a good experience all throughout.
