28 years old, Caucasian female, Light Type II
A 28 year-old Caucasian female presented for an initial visit. Reviewed medical history. Patient reported to have an allergy to Penicillin since birth. Patient also reported to take Sertralin 50 mg once a day for the past 6 months for depression management. Patient reported to stop taking Sertralin 2 weeks ago. Patient emphasized that she did not experience any side effects caused by medication. Patient is non drinker, non smoker. ASA II. Patient reported to use soft bristles manual tooth brush two times a day with horizontal scrub-brushing stroke and Crest Whitening Toothpaste. Patient added that she flosses her teeth once a day, she uses Listerine antiseptic mouth rinse every other day and she brushes her tongue occasionally with a tongue cleaner.
Blood pressure readings was 110/75, pulse 69. ExtraOral examination revealed bilateral crepitus on TMJ, symptomatic, patient reported to have discomfort upon mouth opening and closing. Patient also mentioned to clench her teeth when she is stressed. IntraOral examination revealed enlarged tonsils, patient mentioned to have a mild cold few days ago. Dental: Bilateral Class I Occlusion, tendency to class III, overjet 2 mm, overbite 10%. #18D, #31D are chipped. Gingiva is generally pink , pyramidal on maxillary anteriors, slightly blunted and rolled on mandibular anteriors, not firm, not resilient. Marginal gingival inflammation is present on mandibular anteriors. Patient was qualified as Light type II. Multiple erosions were noticed on the occlusal surfaces of posterior teeth. Patient was interviewed about acidic diet and possible gastrointestinal problems and GERD reflux. Patient reported to eat a lot of fruits and to drink club soda frequently. Patient also reported to have heartburns from time to time. A direct connection between an acid-rich diet and erosions formation were discussed with the patient, nutritional advices and guidelines were provided. In addition to that, patient was given a referral to a gastroenterologist. Oral hygiene instructions were given to the patient. Patient was advised to rinse her mouth with water or Sodium bicarbonate every time after having an acid-rich meal or drinks and to never brush her teeth right after eating an acidic food. Patient was taught a Modified bass toothbrushing technique. Whole mouth was scaled with ultrasonic and hand instruments, engine polishing with a fine prophy paste was performed, 5% NaFl varnish was applied. Recare 6 month.
Few week later after treatment was completed, patient got back to me. Patient said she went to see a gastroenterologist and she was diagnosed with GERD reflux.
