Demographics:

Patient A.B, 31  female  years old, type I Medium. ASA Class I.

Patient was a recall patient and her last visit was on 10/2013. Records indicate her recall visit was scheduled in 6 months/April 2015.

Assessment:

Medical History reviewed. BP: 121/74 P: 67. EO/IO WNL.

Dentition:

Class I class of occlusion. Overjet 3mm. 20 % overjet. No caries.

Periodontal:

Generalized firm, pigmented gingiva with inflamed marginal gingiva of mandibular anteriors linguals and posteriors buccal/lingual surfaces. Probing depths range between 1-5mm. 4-5 mm probing measurements identified on the  mesial and distal of  the maxillary posterior teeth. Minimal BOP with minimal inflammation on posteriors and mandibular anteriors.

 

Oral Hygiene:

Patient was classified as a medium type I. Subgingival calculus detected primarily on the posterior teeth. Supra gingival calculus identified on mandibular anterior lingual aspects.

When patient was disclosed, the disclosing solution was generally accumulated on the interproximal surfaces and mandibular anterior lingual aspect. Initial plaque score was 1.5 and remained the same on the 2nd visit.  During the patient self care, the patient, a continuous user of an electric Oral B toothbrush needed no modifications . She had been previously educated on the significance of using an electric toothbrush. A quick series of questions were asked about the proper use the toothbrush. Instead during the initial visit, OHI included flossing to educate the patient how to properly floss. Patient demonstrated flossing by hugging the tooth with the “ c shape”  in front of a mirror. Patient followed instructions thoroughly.

Radiography:

Treatment management:

Visit 1 -After the assessments and OHI instructions I scaled and completed the LRQ using the  cavitron and hand instruments.

Visit 2.- After re-evaluating the LRQ I saw a slight reduction in inflammation on the posterior LR quadrant and lingual aspect of the mandibular anteriors.  I completed  the patient using the ultrasonic and hand instruments on the UR, UL, and LL. Patient had been polished however refused fluoride treatment. I explained that fluoride treatment increases resistance to decay and afluoridecks but patient showed no interested in the recommend fluoride treatment. Recall visit scheduled in six months.

 

Reflection:
The positive experience that I had with this patient was the time management. She was my first patient from school clinic which worried me at first because I didn’t know how reliable my first clinic patient would be. Fortunately for me the patient showed up for her 2nd visit last minute due to a cancellation . The benefits obtained for my patient includes leaving satisfied with a thorough cleaning. I checked up on my patient to see how her freshly cleaned teeth felt after several days of the cleaning. Patient was very happy with the cleaning and seeks to come back in 6 months for her recall visit. My only weakness during the clinic session with this particular patient  was looking up drug facts and filling out proper paperwork. It was a good experience overall because I learned and performed something I never did from last year’s semester.

 

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