Patient Case Presentation

Patient Profile:
Ms. B is originally from California but moved to Nashville about three years ago to experience
something new. She came to the dental clinic to help out one of her friends and she knew she was
overdue for a cleaning.

Medical History Summary:

Ms. B reported that she does not take any medications, does not have any problems, and is not
allergic to anything. She did state that going to the dentist makes her anxious because of her past
experiences.

Vitals:
BP: 116/74 mm Hg regular, regular
Pulse: 72 bpm steady
RR: 14 rpm deep
O2: 99%
Temp: 97.7 F

Summary of Health:
The patient is a 25-year-old Caucasian female who presents in good health. She does not take
any medications and she is not allergic to anything. She smokes nicotine from a disposable vape
daily (10 or less hits) and smokes marijuana every night (2 hits).

Past Dental History:

The patient was seen about three years ago by a dentist in California for a routine cleaning but
since she moved to Nashville three years ago she has not been to a dentist.

Chief Complaint:
Ms. B came to the dental clinic because she was “helping out my friend and I haven’t had a
cleaning in a few years.”
Clinical Findings:
Extraoral Examination:
Scattered freckles and macules ranging from 4x3 mm to 1x2 mm. She does not have any
palpable lymph nodes or any irregularities within her glands.

Radiographic Findings:
Horizontal and vertical bone loss in the beginning stages throughout the mouth. Slight
radiographic calculus in a few spots and recurrent caries was detected on the distal of #8.

Intraoral Examination:
Bilateral linea alba and bilateral lip pits were present on the patient's buccal/labial mucosa. A
palatal torus was present on the palate. The patient’s tonsils were present and presented slightly
inflamed. Tooth #8 had recurrent caries on the distal aspect.

Caries Risk Assessment:

Moderate. The patient has a permanent retainer on the lingual side from #22 to #27 and snacks
throughout the day.
Gingival Assessment:
The gingiva was inflamed and appeared red throughout the mouth. The tissue on the facial aspect
of #21 to #27 and #7 was more inflamed and red than the other tissue. There was bleeding
throughout the entire mouth.

Periodontal Examination:
The patient presented with generalized periodontitis. Calculus was generalized throughout the
entire mouth as well with the heavier deposits mostly on the lower anterior around the permanent
retainer.

Probe Readings:

Dental Hygiene Diagnosis:

Loss of attachment is present throughout the mouth along with radiographic bone loss. The
patient presents with Stage 1, Grade C periodontitis.
Dental Health Education:
Plaque Control Record: 35%
The patient brushes twice a day with a Sonicare toothbrush but does not floss very often. The
bass technique was recommended and reiterated that the Sonicare toothbrush does the work for
her. Reviewed the proper way to floss using C shape motion so that she is able to remove more
biofilm around the gum line and around her permanent retainer.

Planning:
Because of the calculus deposits, bone loss that has already started, loss of attachment, and large
amount of bleeding, this patient would benefit from four quads of nonsurgical periodontal
therapy. Local anesthesia should be performed before instrumentation. With proper home care
regimens and nonsurgical periodontal therapy, the patient and her tissue should respond well.

Goals:
1. Improve the health status of the gingiva, teeth, and supporting ligaments throughout the
mouth.
2. Remove all calculus deposits along with removing biofilm.
3. Introduce an oral hygiene regimen so that the patient is able to disrupt biofilm each day.
4. Reduce periodontal pocket along with bleeding.
5. Encourage the patient to come in every 3 months for periodontal maintenance recare
appointments.

Initial Treatment Plan:

Appointment 1:
Medical and dental history
Intraoral and extraoral examination
Complete series of x-rays
Periodontal charting, Calculus detection, Gingival assessment
Treatment plan proposal and acceptance
Comprehensive examination
Appointment 2:
Plaque score and OHI
NSPT on quad 2 and 3 with local anesthesia

Appointment 3:
Plaque score and OHI
NSPT on quad 1 and 4 with local anesthesia

Appointment 4:
Periodontal Re-Evaluation
Review oral hygiene care
Reiterate goals

Appointment 5:
Recare visits in 3 month intervals

Implementation:
The treatment proceeded as planned. The was receptive and showed signs of improvement. The
patient was able to demonstrate proper skills with brushing and flossing techniques. She
continuously decreased her plaque score each time she came in.

Treatment Revisions:
Appointment 4
Observed healing throughout the mouth. A piece of calculus was missed on the distal of #7 so
this was removed during the re-evaluation appointment. This was extremely far subgingival but
once it was removed, the gingiva responded immediately and showed signs of inflammation
going away.

Evaluation:
Ms. B was treated in the dental hygiene clinic for a period of a month and a half. The
re-evaluation appointment indicates that she is responding well to treatment and cooperating.
The patient can demonstrate an adequate technique for brushing and flossing. She can effectively
remove plaque and has incorporated all of my recommendations into her daily routine. I
discussed continuing home care to maintain the state of health she is working towards. The final
plaque control record was 19%.

Results:

The patient responded well to Nonsurgical Periodontal Therapy. The tissue improved
tremendously throughout the oral cavity. Ms. B will come in every 3 months for periodontal
maintenance recare appointments to maintain her oral cavity health.