25 year old Bangladesh male BP: 128/82 P: 73.
Pt. has never had a dental cleaning.
Pt. does not have any medical conditions and is not taking any medications. Pt. states that he smokes 3 cigarettes a week.
EOIO: Within normal limits. Dental Charting: Partially erupted: #17 and #32 and suspected carious lesions on #32-O.
Perio: Generalized 2-3 mm on anterior teeth and 3-5 mm on posterior teeth with severe bleeding upon probing.
Patient’s gingiva was red and edematous with bulbous interdental papilla.
Calculus: Generalized heavy subgingival calculus, supragingival calculus on maxillary anterior- facial aspect and mandibular anterior- lingual aspect.
Patient also had light staining on maxillary anterior- lingual.
Patient is H/II because there was slight bone loss as evidenced by 4BW’s.
Treatment: V1: Pt. was taught how to floss properly and was educated on the importance of flossing daily 1x/day. Pt. was told to rinse 2x/day with Listerine.
V2: Pt. was taught the proper brushing method and was recommended to switch to an electronic toothbrush
Patient was scaled using hand instruments followed by a lavage using ultra sonic inserts.
When patient came back for a second visit, severe bleeding was present on previously scaled areas although no calculus deposits were present.
It is suspected that the pt. may have an underlying bleeding condition and there will be a follow-up with pt. on next recare visit.
Pt. was placed on a 3 month recare appointment.