Academic Examples

patient: W.A., age 37

Patient health history: W.A. has had asthma as a child because of allergies, but has not had an attack since age 13. Patient has enlarged tonsils, she knows about them and said they have always been that big. She is currently not taking any medications, but has an IUD, Mirena, which does release hormones but there are no oral effects.
Dentition: This patient has been here before, and since her last visit she has two new class I composite restorations on #’s 1 and 16.
Periodontal: This patient had minimal BUP and had generalized pocket depths of 1-3mm with one reading of 4mm on the mesio-buccal aspect of number 14. She has recession of 1mm on the buccal aspect of mandibular molars. This is giving her some dentinal hypersensitivity, more noticeable on the left side. During the appointment I applied Colgate desensitizing paste (ACP plus arginine bicarbonate) to the areas, burnishing it in, and letting it sit and she had some improvement.
Oral Hygiene: This patient was classified as a medium. The calculus deposits were generally sub-gingival, but localized supra-gingival was on the lingual aspect of the mandibular anteriors. The sub-gingival deposits were more numerous on the mandible than the maxilla and were generally interproximal. Plaque score was 5/6, which is considered “good.”
Radiographs: W.A. had bitewings taken this time last year and she had a PAN in 2010. They both showed no significant findings.
Time: This patient was last here in October of 2011. I absolutely think she should have been coming every six months. The last two times she was here she was a light case value, when she was coming twice a year. Now that a full year has passed, she is a medium. I explained to her the importance of regular visits and how now there is a larger build of calculus in her mouth.
Treatment Management: This visit, after assessments, I scaled the UL and LL. As mentioned earlier I used the desensitizing paste on her teeth in the reported sensitive areas and also gave her samples of sensodyne toothpaste to use at home. I recommended she apply it at night before bed in the specific areas to help with sensitivity as needed. She doesn’t always have pain, but now she will have something for when she does. Because she recently had restorations, next visit I plan to use the caries risk assessment form as well as scale the UR and LR. I think a weakness this clinic session was time management. Because the patient arrived 25 minutes late, I felt like I wasn’t going to finish her in one visit so I took my time scaling. If I didn’t make up my mind so early on, and worked a little bit faster I might have finished one more quadrant if not the entire dentition. I think my strength was how I relate and speak to my patients. I feel I have a good ability to get on the same level of awareness as the patient and make them see beyond it. I love when you can see the “light bulb” go off in their heads; even if is just them now understanding why regular 6 month visits (in her case) are so very important not just for the oral cavity but for her general overall health.