Patient profile

    Mr. M is a 45 y.o. Caucasian male presented for a dental cleaning. Single, non-smoker, no allergies reported, and consumes 1 glass of wine occasionally. Patient states he uses a manual toothbrush and power Sonicare toothbrush 2x/day, Colgate dentifrice, flosses rarely 1x/week, and uses mouthwash every day, 2x/day.

Chief complaint: “I need a dental cleaning”

Vitals: BP:  141/89 corresponding to hypertension II, P:73.  ASA 2

Med/dental Hx: Reports no hospitalizations in the last 5 years. Medications: Amlodipine/Olmesartan combined medication 1x/day for High Blood Pressure and Trulicity as needed for weight loss. His last physical exam was two months ago. His last dental checkup was at NYU Dentistry a few weeks ago and had FMS radiographic images taken, his last dental cleaning was a year ago. Pt had orthodontic braces treatment 25 years ago and does not wear retainers.

Clinical Findings

Extraoral/Intraoral findings: dry lips, lingual frenum. Bilateral linea alba. Occlusion: molar relation Class I bilateral. Crowding was noted on mandibular incisors. Overjet- 3mm. Overbite- 30%. Localized attrition on anterior incisors. Gingival statement: generalized red color of the gingiva, fits enlarged around the teeth, interdental space is filled with pyramidal shape bulbous papilla, rolled gingival margin, soft consistency, and smooth texture. Calculus: Localized supragingival calculus and brown stains on mandibular incisors and moderate subgingival interproximal calculus noted.

Dental Charting:

  • Amalgam restorations : #3-M, #14-O
  • Composite restorations: #1-O, #12-DO, #16-O, #17-O, #18-O, #31-O and #32-O
  • Inlay on #5-O and 18-DO
  • Sealant on #19
  • Caries lesions: #3-O, #4- D, M, #5-D, #16-M

Periodontal Charting:

  • Generalized moderate bleeding on probing
  • Proping depth ranges between 2-3 mm on anterior teeth and 4-6 mm on posterior teeth.
  • Gingival recession on several mandibular posterior teeth 1-2mm and mandibular incisors lingually 1mm

Periodontal Diagnosis: Periodontitis Stage II/Grade B (without radiographic evidence). Caries risk– High due to active caries lesions. Case value–Medium.

Dental Hygiene Care Plan

Visit 1: OHI- introduce the spool floss technique. Nutritional counseling. Apply Oraqix (2.5%/2.5% lidocaine/prilocaine) for pain management. Ultrasonic and hand scale Q1 and Q4. Give referral to see a dentist for #3-O, #4-D, M, #5-D, 16-M, and to see a physician for HBP.

Visit 2: OHI- introduce the powered toothbrush technique. Apply Oraqix (2.5%/2.5% lidocaine/prilocaine) for pain management. Ultrasonic and hand scale Q2 and Q3. Apply 5% varnish fluoride.

Implementation

1st visit summary:  All intake data was collected, and the Tx plan was signed by the patient. PI/OHI- introduced spool floss technique. Nutritional counseling – discussed diet with the patient and explained the consequences of a non-healthy diet. Applied Oraqix (2.5%/2.5% lidocaine/prilocaine) for pain management. Ultrasonic and hand-scaled Q1 and Q4. The referral was given to see a dentist for #3-O, #4-D, M, #5-D, 16-M, and a physician for HBP.

2nd visit summary: Re-evaluated scaled Q1 and Q4 on the last visit. The patient had significant improvement in tissue response on scaled Q1 and Q4. Was noted a decrease in gingiva inflammation, the pink color of the gingiva noted, snugly fitted around the teeth, pyramidal shape interproximal papilla, and stippled texture. PI/OHI- introduced powered toothbrush technique. Applied Oraqix (2.5%/2.5% lidocaine/prilocaine) for pain management. Ultrasonic and hand-scaled Q2 and Q3. Applied 5% varnish fluoride with post-op instructions. The patient was given samples of Sensodyne nourish toothpaste and Listerine Total mouthwash.

Continued Care Recommendation: 3 months of re-care was recommended to the patient due to the diagnosis of periodontitis and supragingival calculus accumulation.