Ms. D, a 39-year-old Asian female, came into the clinic after her dentist informed her that she needed a deep cleaning. Her vitals were 99/63, and she had a pulse of 63. The patient was ASA2. She is allergic to Amoxicillin. She stated that she had fibroids surgery in August 2020 and that she had gestational diabetes during pregnancy but returned to normal after labor. The patient smokes e-cigarettes on a daily basis but does not consume alcohol. Her most recent dental exam and cleaning were performed in June 2022, and a panoramic digital image was taken in August 2022.
The palatal torus and mandibular lingual short frenum were noted during the extraoral and intraoral examination.
The patient has bilateral Class I occlusion. She has a 2mm overjet and a 5% overbite with an anterior edge-to-edge bite. She has generalized mild attrition. Fractures were seen on #30 and #31. #18 and #30 had Class II furcation involvement, with #18 having Class II mobility. Tooth #16 and #17 were not clinically presented.
Her gingiva was generalized cyanotic and rolled, enlarged in size with a thickened edge, shiny in texture, and bulbous interdental papilla. The anterior facial aspect was found to be flaccid. The patient had generalized severe inflammation as well as BOP.
The patient’s periodontal assessment indicated she had generalized 5-9mm PD and localized 1-2mm recession on the canines and second premolars. Generalized heavy supragingival and subgingival calculus was found.
The panoramic digital image presented by the patient revealed generalized significant bone loss more than 30%. PAP is also noted on the apex of #19.
The onboard dentist confirmed that the patient’s case value was heavy periodontitis Stage IV Grade C, which was beyond our scope of practice.
Informed and explained to the patient her oral condition. The patient was aware of the limitations of the non-surgical periodontal treatment we could provide while she required more advanced periodontal treatment. A referral was given to her for periodontal evaluation.
