S: 34 years old African American female presented for “a dental cleaning”. Mex Hx: reviewed, no prescribed or over-the-counter medications are taken, no vitamins or supplements. ASA II, patient states to have an allergic reaction to aspirin in a childhood which was expressed as “heart burn feeling”. Pt had surgery done in 2016 (post complications from hemorrhage removal surgery done in 2015). Last physical exam in February 2019 in Kenia. Pt never had the dental cleaning done either radiographs were taken. States to have general sensitivity to cold. Pt reports using powered Oral B tooth brush with soft bristles, brushes two times a day, prefers Colgate Total mint as dentifrice. Pt reports the attempt to use floss but “my teeth are so narrow, that it is too hard to floss”. Does not use mouth washes or tongue cleaners.
O: Blood Pressure readings: 107/81 Pulse:108. Student was not able to perform the Extra Oral Examination due to patient presented with collar splint on the neck. Patient reports right unilateral pain on the neck due sleeping on the wrong position. TMJ was checked: WNL. IO: Bilateral cheek bite, prominent bilateral linea alba. Elongation of filliform papilla on the dorsal surface of the tongue. Maxillary tori. Dental:Class of Occlusion I, overjet 3mm, overbite 10%. Attrition was noted on the #22-25. Generalized flattening and cupping of occlusal surfaces of the mandibular and maxillary posterior teeth. Gingiva: generalized pigmented, well contoured, soft gingiva, moderately inflamed, mild BOP. Recession were evident on the maxillary molars(palatal). Biofilm: not evident, but heavy supragingival calculus accumulations were present on the lingual of mandibular anterior teeth, as well as generalized heavy subgingival calculus deposits.
A:H/I
P: Assesments were completed, flossing was introduced as OHI. Scaled UL quadrant using ultrasonic and hand instruments. Topical gel was applied (20% benzocaine). Local anesthesia was given: PSA, MSA, ASA injections were given by faculty ( 2 carpules of 2% lidocaine with 1:100.000 epinephrine), negative aspiration, patient tolerated it well. Referral was given for caries evaluation and patient was advised to see therapist for possible GERD. Next visit: Expose FMS, proceed according to treatment plan.
Patient did not come back for completion of treatment due to shortage of available afternoon clinic days requested by patient and his willing for the treatment to be completed within 2-2.5 weeks period before his religious holiday. It was explained to patient that teeth morphology are wearing away due to the possible acid that coming form the stomach. Pt was not aware of the condition, but admitted that he has a “heart burn feeling” sometimes.
