JOURNAL – RECALL PATIENT
 C.S., 69, M/II, localized type III
ASSESSMENT
A. Patient health history and vital signs
This patient is a Caucasian male. His blood pressure is 117/77 and his pulse is 59. The patient has a history of Hepatitis C. He stated that he tests positive for the antibodies and has since 1991. He has not had any manifestations of the disease and is not currently seeing a specialist for treatment. This patient takes 81mg a day of aspirin as an anticoagulant. Aspirin can cause increased bleeding with dental treatment. He also takes 10mg a day of Simvastin for high cholesterol. He does not require premedication.
B. Oral Pathology
The patient did not have any abnormal or pathological findings requiring a referral.
C. Dentition
    This patient has numerous restorations. He has two bridges and a partial denture in place of tooth #31. The patient has attrition on teeth 23-26 and 6-10. He has an active carious lesion on the buccal root of #18, located under the margin of a crown. Since he has active root caries, a history of caries, and numerous exposed root surfaces, including one with caries he is classified as high caries risk.
D. Periodontal
The patient has generalized mild inflammation. He has light pink gingival and is missing his interdential papilla. He also had localized recession in the posteriors and generalized recession in the mandibular anteriors. He mainly had 1-6mm pockets with one 10mm pocket on the buccal of #18. He also has a type 1 furcation on #19 and 30 and a type 3 furcation on #18. Because of his recession he had 5-7mm of CAL on the mandibular anteriors and 8-10mm of CAL on the buccal surfaces of the mandibular molars. He is classified as type II periodontitis with localized type III. Based on the assessment Arestin is not appropriate for this patient because he only had three 5-6mm pockets and had severe recession.
E. Oral Hygiene
The patient is classified as a medium type case. He had moderate subgingival calculus on his mandibular teeth and heavy supra gingival calculus on his mandibular anteriors. He barley had any calculus on his maxillary teeth. To find out about his oral hygiene I interviewed the patient about his current homecare routine. He told me he purchased the Oral B brush from the clinic used it once a day. I recommended that he use it twice a day and we went over how to adapt the brush to the tooth on the first visit. On the first visit his plaque index was a 1.3 which is classified as fair. On the second visit his plaque score improved to a 1.0, which is classified as good. We then went over flossing. The patient stated that he flossed once a day and also used a threader to clean under his bridges. He demonstrated his technique to me and I only had to make a few small corrections to perfect his technique.
F. Radiographs
This patient needed a FMS. He did not have any radiographs for review in his chart and has been coming to our clinic since 1995! So I took a FMS on the first visit and reviewed the findings with him on the second visit. The radiographs revealed about 1-2mm of generalized bone loss, which confirmed the clinical findings. They also revealed that he had a type 3 furcation on tooth #18, I knew there was a furcation there because there was a10mm pocket but I was not able to use my furcation probe to identify the type of furcation due of root caries on the tooth.
The radiographs also helped me identify which teeth were present in his mouth and which were pontics in a bridge.
TIME:Â The time between the patients last appointment was 18 months. I think he should have come back after 6 months because he was classified as a light at his last visit, but he said his appointment last fall was canceled because of hurricane Sandy and he never rescheduled it. I recommended a 4 month recall.
TREATMENT MANAGEMENT
During the first appointment I reviewed the medical history, completed all assessments and taught brushing for oral hygiene. I then scaled teeth #6-8 with my hand instruments and took a FMS. The second visit I taught flossing for oral hygiene and reviewed the radiographs with the patient. I then scaled the remainder of his teeth with ultrasonic’s and hand instruments. I polished and applied fluoride varnish.
Based on my analysis and interpretation of the data gathered during the assessment, I made multiple recommendations. Because he is caries active and has severe recession I recommended that he come every 4 months for a fluoride varnish application. Also, since he has medium deposit I changed his recall to 4 months.
I feel that my strength with this patient was time management while taking the FMS. I didn’t have much time to take it and was able to get it done in 45 minutes, including setting up the room, taking the radiographs, processing and mounting. This was the 4th FMS series I took so I’m getting much quicker at it.
My weakness with this patient was dental charting. He had very complex charting and I had trouble identifying two pontics. I had learned about pontics before but had never seen one in clinic so I thought they were crowns. The previous dental charting in his file also had numerous mistakes in it; I caught a few but not all, so it ended up confusing me more in the end. My instructor pointed out the mistakes and I completed a new accurate chart for his file and entered it in the computer properly so there will not be any confusion in the future. It was also much easier to understand what exactly was going on in his mouth when I had the radiographs.
This patient was referred to a DDS for caries evaluation on tooth #18.
JOURNAL – NEW PATIENT
M.G., 20, H/II
ASSESSMENT
A. Patient health history and vital signs
This patient is a Hispanic male. His blood pressure is 125/70 and his pulse is 72. This patient is in good health and is not on any medications. He does not require premedication.
B. Oral Pathology
The patient presented a gingival abscess that was 3x3mm on the buccal mucosa between teeth #2 and #3. The abscess is round, raised, light pink and filled with fluid. It coincided with tooth #3 which was partially missing and infected. On the second visit, about 20 days later it grew to 4x5mm was round, raised, filled with fluid and red with white areas. The patient was given a referral on both visits and my faculty and I explained how important it was that he goes to the dentist as soon as possible. On the second visit he stated that he made an appointment with his dentist, but it wasn’t for a few weeks so he was going to make it sooner.
C. Dentition
    This patient has attrition on tooth #28 and has a class I occlusion. Teeth #1 and #16 were partially erupted. He has active caries on the lingual pit of #6, the buccal pit of #31 and the mesiolingual surface of #19. All that was remaining of tooth #3 was a partially retained root, the entire crown was missing. Since he has three active caries he is classified as high caries risk.
D. Periodontal
The patient has severe generalized inflammation. His gingival is red and spongy and he has extremely bulbous papilla. He also had localized recession on the buccal surface of the mandibular posteriors and generalized 2mm of recession on the buccal surface of the mandibular anteriors. He had 1-6mm pockets, but because of his recession he has 4-6mm of CAL in the buccal surface of the mandibular anteriors. He is classified as type II periodontitis. Based on the assessment Arestin would be appropriate for this patient because he had 21 sites with 5-6mm probing depths.
E. Oral Hygiene
The patient is classified as a heavy type case. He has generalized heavy subgingival calculus. To find out about his oral hygiene I interviewed the patient about his current homecare routine. He told me that he brushed with a manual brush twice a day. I recommended a powerbrush because of his heavy deposit. He also stated that he never flossed. So I recommended that he floss daily. He also said that he used Listerine occasionally so I explained how to use it properly and to use it twice a day.
On the first visit his plaque index was a 2 which is classified as poor so we went over toothbrushing. On the second visit his plaque score improved to a 1.5, which is classified as fair. So we then went over flossing. This patient had a very difficult time handling the floss; he was unable to make a “C” around the tooth with the floss, even after I showed him multiple times and tried to assist him. He was also unable to get his fingers back around the posterior teeth. So we gave up on the regular floss and I recommended that he use a reach flosser or the flossing picks instead.
F. Radiographs
This patient needed a FMS. He had not had any radiographs in at least 5 years. He also had active caries, periodontal disease and an abscessed tooth. So I took a FMS on the first visit and reviewed the findings with him on the second visit. The radiographs confirmed periapical pathology around the root of #3, which correlated with the abscessed tooth. It also showed that the infection was resorbing the bone in the surrounding area, which could impact teeth #2 and 4. The radiographs also revealed about 1 mm of generalized bone loss on the anteriors and microdontia in the maxillary 3rd molars.
G. Other findings:
The abscessed tooth could significantly impact the patient’s oral and overall health if he does not get treatment. But he does not smoke or drink alcohol regularly or have any other significant factor that could impact his oral health.
TIME:Â The patient has not had any hygiene services since 2011, so it had been about two years since his last cleaning. I put him on a 3 month recall because he was a heavy case type and had poor oral hygiene. I would also like to follow up with him regarding tooth #3 to make sure he went for treatment.
TREATMENT MANAGEMENT
During the first appointment I reviewed the medical history, completed all assessments and taught brushing for oral hygiene. I then took a FMS. The second visit I taught flossing for oral hygiene and reviewed the radiographs with the patient. I then scaled all four quadrants with ultrasonic’s and hand instruments. I polished and applied fluoride varnish.
Based on my analysis and interpretation of the data gathered during the assessment, I made multiple recommendations. Because he is caries active and has some recession I recommended that he come every 3 months for a fluoride varnish application. Also, since he has heavy deposit I set his recall to 3 months.
I feel that my strength with this patient was dealing with a difficult patient; he was over an hour late for the first appointment and nearly 30 minutes late to the second. It was also very difficult to scale him, he was extremely sensitive so I had to give him oraquix and he was still sensitive in some areas. He also kept sitting up to spit in the cuspidor every few minutes. I had the suction in and it was working, he just didn’t like using it and kept taking it out of his mouth.
My weakness with this patient was teaching oral hygiene. His plaque score improved from the first visit, but was still not very good. He also had an extremely difficult time flossing. I tried my best to teach him, but he just didn’t get it. He was unable to control his fingers in his mouth and was getting frustrated. Hopefully he will just use the picks like we discussed and won’t be so discouraged that he won’t floss at all.
This patient was referred to a DDS for extraction of #3 and caries evaluation on teeth #6, 19, and 31.
