Patient Case Presentatioin

RDH 2810
PATIENT CASE PRESENTATION
PATIENT PROFILE: Mrs. A is a 39-year-old Hispanic woman. She lives in Tennesse. She
came to the dental school to get a cleaning because her last cleaning was over a year ago.
MEDICAL HISTORY SUMMARY: Mrs. A does not have any medical conditions and she
does not take any medications. She does have an allergy to penicillin and ibuprofen.
The patient's family history did not reveal any medical conditions. She has three children, who
are healthy.
VITALS (as of 2/14/2024)
BP: 120/78 steady and strong
PR: 76 bpm steady and strong
RR: 14 rpm, easy and unlabored
O2: 98%
TEMP: 97.6 F
SUMMARY OF HEALTH
Patient is a 39-year-old Hispanic woman in relatively good health. No medications or conditions
to note. She has an allergy to penicillin and ibuprofen
PAST DENTAL HISTORY: The patient was seen by a private dentist about 2 years ago to have
her teeth cleaned. She has not been to a dentist since then.
CHIEF COMPLAINT: Mrs. A did not have any chief complaint at any of her appointments.
She said that everything felt “bueno”
CLINICAL FINDINGS:
Extraoral examination:
 Extraoral Exam - Gait: straight
o Face/head/neck: 4x5mm circular mole above left eye;generalized macules ranging
from 1x1 mm to 3x3mm across bridge of nose and cheeks
o Lymph nodes: not palpable or enlarged
o Glands. not swollen or enlarged
 TMJ: bilateral clicking and popping during vertical excursion; patient complains of pain
on left side during opening and closing; full range of motion
Radiographic findings: Horizontal bone loss present between all mandibular anterior teeth and
the molars of the mandibular and maxillary arch. Radiographic calculus is apparent, primarily on
the interproximals of the mandibular anterior teeth. Caries observed on #13 DO. We are keeping
a monitor on #4 distal, #5 distal, #12 distal, which all have existing fillings
Intraoral examination:
 Intraoral Exam - Labial buccal mucosa: smooth
o Palate: smooth; no torus
o Oropharynx: not red or inflamed
o Tongue: moist, pink
o Floor of mouth: smooth Salivary flow: free-flowing
o Frenum attachments: in-tact
o Lymph Nodes: not enlarged
o Glands: not enlarged or tender
Caries observed on #13 DO. We are keeping a monitor on #4 distal, #5 distal, #12 distal, which
all have existing fillings.
 Angle's Classification of Occlusion (right and left): bilateral class II canine and molar
relationship
 Overbite: moderate
 Overjet: 5mm
 Midline: midline deviation 2mm to the left
 Crossbite: none
 Tooth Alignment: none
 Open contacts. none
 Parafunctional habits: none
Caries Risk Assessment: moderate due to interproximal restorations
Gingival Assessment: The gingiva was inflamed and edematous with generalized bleeding.
GINGIVAL DESCRIPTION
 Color: light red
 Size: flat
 Margin Position: at or slightly apical to CE
 Margin Shape: scalloped
 Papilla shape: pyramidal
 Texture: smooth
 Consistency: spongy
 Localized Gingival findings: generalized BOP
Periodontal examination: The patient presented with generalized periodontitis. Calculus was
generalized throughout the mouth with the heaviest deposits located on the lingual side of the
lower anterior teeth.
Periodontal Assessment
DENTAL HYGIENE DIAGNOSIS:

Radiographic loss of attachment interdentally mainly in sextant 5 and generalized on the
posterior teeth. Probing depths 3-6 mm with bleeding present on probing
The patient presents with Stage 1 Grade A periodontitis.
DENTAL-HEALTH EDUCATION:
Plaque Control Record: 37% (as of first visit)
Mrs. A brushes her teeth twice a day but does not floss regularly. The Modified bass technique
was recommended twice daily along with string floss for interdental flossing. Instructed the
patient to conform the floss in a C shape below the gingival margin to remove biofilm using the
tell, show, do method. I also recommended using a fluoridated toothpaste and mouthrinse with a
2 min brush time at least twice daily.
PLANNING:
Rationale for case selection:
Due to the depth of periodontal pockets with bleeding on probing, and the radiographic
attachment loss, Non-Surgical Periodontal Therapy was selected as the best treatment option for
Mrs. A. Anesthesia should be administered to keep the patient comfortable, especially when it
comes to the deeper periodontal pockets. Antibiotic therapy may accompany treatment after
debridement.
Goals:
1. Improve the pocket depths
2. Improve the health status of the gingiva, teeth, and supporting ligaments, especially in the
lower anterior area.
3. Improve plaque score by next visit
4. Remove all biofilm as well as calculus deposits.
5. Get patient to set a better at-home oral hygiene routine to keep up in between recare
appointments
6. Encourage the patient to remain on a preventative 3 month recare routine.
Initial treatment plan:
Appointment 1:
 Medical and dental history
 Intraoral, extraoral examination
 Questionnaires
 Complete series of radiographs, panoramic, and vertical bitewings
 Complete gingival assessment and periodontal evaluation
 Calculus detection
 Comprehensive examination
 Treatment plan proposal and acceptance
Appointment 2:
 Updated medical history
 Vitals
 Updated EO/IO
 Plaque score
 Oral Hygiene Instruction – with emphasis on using a powered toothbrush, water flosser,
and string floss regularly
 Performed local anesthesia administration to quadrant 1
 Completed debridement in quadrant 1 with cavitron
Appointment 3:
 Vitals
 Updated EO/IO
 Plaque score
 Performed local anesthesia administration to quadrant 4
 Completed debridement in quadrant 4 with cavitron
Appointment 4:
 Vitals
 Updated EO/IO
 Plaque score
 Performed local anesthesia administration to quadrant 2 and 3
 Completed debridement in quadrant 2 and 3 with cavitron
IMPLEMENTATION: The treatment proceeded as planned. Mrs. A was receptive to

all procedures. She handled the anesthesia very well. She remained calm the entire time and did
not seem nervous at all. Despite the language barrier, we were able to navigate through all
appointments via an online translator. No skill roadblocks were encountered with dental health
education. The patient was able to demonstrate adequate skills with a modified bass brushing and
flossing technique. I recommended a powered toothbrush and a two minute brush time at least
twice daily. The plaque index decreased steadily and I congratulated my patient for that! Hygiene
procedures were accomplished with minimum difficulty.
Treatment revisions:
Appointment 5: (Re-eval)
 Updated EO/IO
 Follow-up periodontal charting
 calculus detection
 Dental health education: review oral hygiene care via google translate and discussed what
patient was doing at-home
 debridement of entire mouth using cavitron and hand instruments
EVALUATION:
Mrs. A was treated in the dental hygiene clinic for a period of 4 months. The re-evaluation
assessments indicate that the gingiva in the maxillary anteriors and mandibular anterior areas
were still erythematous and had deeper pockets. There was an overall reduction in probing depths
and bleeding apart from maxillary anteriors and molars
The patient can demonstrate an adequate technique for brushing and flossing. She struggles a
little bit with at-home hygiene care. She said she brushes for 30 seconds twice daily and flosses
sometimes. Continued home care has been reinforced to improve this area. The final Plaque
control record was 55%
RESULTS:
Mrs. A seemed to enjoy the entire treatment process. She seemed very receptive to the oral
hygiene instructions I gave her. The patient responded well to Nonsurgical Periodontal Therapy.
Tissue resolution, color, and consistency have improved throughout the oral cavity. Bleeding has
decreased significantly upon probing after debridement, although I would like to see more
improvement.
Mrs. A will continue with restorative treatment and will be treated with periodontal maintenance
every 3-4 months.

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RDH 2810

PATIENT CASE PRESENTATION

Caries Risk Assessment: moderate due to interproximal restorations

DENTAL HYGIENE DIAGNOSIS:

IMPLEMENTATION: The treatment proceeded as planned. Mrs. A was receptive to

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