Case study 1.

Patient Profile

32 years-old Mexican male presents for check up and cleaning.
Middle class, working in the field of service, lives with wife and 4 kids, unfortunately he has not had dental insurance and has to pay out-of-pocket for dental care.
Last dental check up was done Fall 2016. Newer have dental Radiographs.

Patient stated that he is brushes and flosses 2 times a day using a soft manual toothbrush, using mouth rinse 1 time a day.

Patient is a smoker, and social drinker.

Medical history: patient is asthmatic, with age it become better, the only trigger that he has now is winter cold weather or being in the mountains. During asthma attack patient using inhaler. Last episode of asthma attack was this winter when he went to ski. He has family history of asthma; his mother is asthmatic. I asked patient to take inhaler to his appointment.

Assessments:

Extra oral examination: NSF
Intra oral examination: geographic and fissures tongue
Dental charting: mandibular third molars were impacted, no composites or any other dental restorations. Suspicious carries lesion on tooth #31, due to impacted #32 and difficulty of cleaning in that area.
Class I of occlusion bilaterally.
Overjet 3 mm, Overbite 30%.
Calculus and biofilm deposits: bridge of calculus on lingual surfaces on mandibular teeth, supra and subgingival deposits on Maxillary anterior (facial and lingual) surfaces. Generalized subgingival calculus deposits on posterior teeth.
Soft biofilm mostly interproximal, and on the lingual side.

Gingival statement: gingiva red, inflamed, bulbous, irritated, easily bleeding by touch.

Periodontal depth generalized were 3-5 mm deep, localized 6-7, due to inflammation. Patient has severe gingivitis and inflammation.

TX plan: Panoramic and horizontal bitewings, oral hygiene instructions: first visit – flossing, next visit – brushing. Scaling with ultrasonic and hand instruments was divided in 2 visits, to monitor the gingival changes, engine polishing, fluoride 5% varnish treatment. Adult referral given to patient for evaluation with specialist about 3th molars and handed printed copy of x-rays. Adult sealants on all molar teeth were approved.

Findings from assessments was discussed with a patient, radiographic findings discussed and addressed patient attention to referral for a specialist.

Discussed with patient home care, stress the importance of brushing and flossing in his situation. Made appointment in a few weeks for adult sealants and for reevaluation of healing process of gingival tissue.

Complications and challenges: during scaling my biggest compilation was bleeding. Bleeding was so strong, that after removing big piece of calculus I have to hold gauze for a minute or so, just to stop bleeding.

Patient was recommended 3-month recare.