Download Periodontal Case Study Project

PERIODONTAL CASE STUDY
PROJECT
Dental Hygiene Clinical Practice II
Patient Profile
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18 year old Hispanic
male
Health history reveals:
No medications
Vitals signs WNL
ASA class I
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Dental history reveals:
Brushing with a
medium toothbrush 1x
day (AM)
Flosses once in a while
Last dental visit dated
6 months ago
Extra Oral and Intra Oral Findings
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Mucosa: Gingival
pigmentation
Frena: Max skin tag
Alveolar ridges:
Keratinized on distals of
#’s18 and 31
Attrition: Slight attrition
on #”s 4,6,7,10,11,2227
Fluorosis: Generalized
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Overbite: Slight 25%
Overjet: 3mm
Labio/linguoversion:
Labioversion #’s 8 & 9
Torsoversion: #’s 21 &
28
Angles classification:
Tendency to class III
(molar & canine right)
Tendency to class I
(molar & canine left)
Intra Oral Photos
Intra Oral Photos
Intra Oral Photos
Dental Chart
Periodontal Charting
Periodontal Evaluation
Assessments Findings
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Class I furcation on the buccal aspect of tooth #15
No mobility or mucogingival involvement
BOP was observed on #’s 3,4,5,8,11,12,14,15,20,21,28,30
Slight spicules of supragngival calculus on all maxillary and
mandibular teeth
Generalized spicules of subgingival calculus on the mandible with
localized spicules on #’s 2,3,12,14,15
Generalized slight biofilm interproximally.
Plaque Control Record was 9%
No stains
Defective sealants on #’s 3,19 & 30 with a watch on tooth #14
Teeth #’s 1,17 & 32 are partially erupted
Gingival Description
Generalized pigmented, thickened, spongy, slightly
enlarged papillae on the maxillary and mandibular
anteriors with stippled tissue.
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Contributory Factors: Nutritional deficiencies
Obesity: Yes
Periodontal Risk Factors: N/A
Radiographs
Generalized slight bone loss
Radiographs
Radiographs
Radiographs
Periodontal Diagnosis
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Generalized slight active chronic periodontitis
AAP Case Type: II
Procedures
First visit
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Medical History, EOE, IOE, Vital Signs, Dental Charting and GM(maxillary)
 Second visit
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RMH, EOE, IOE, Vital Signs, GM, periodontal exam
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Plaque index & education
- Reviewed brushing technique using a modified bass method
 Third visit
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RMH, EOE, IOE, Vital Signs, Deposit Assessment
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Plaque index and education
-Reviewed brushing technique and introduced flossing technique
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Debridement of the maxillary right using mgnetostrictive power inserts (XT Modified
universal) then followed by hand instrumentation
 Fourth visit
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FMX
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Procedures
Fifth visit
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RMH, EOE, IOE, Vital Signs
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Plaque index and home care
-Both brushing and flossing technique have improved; patient is now using a soft toothbrush
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Re-asses URQ
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Debridement of the maxillary left using magnetostrictive power inserts (XT Modified universal)
then followed by hand instrumentation
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Sixth visit
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RMH, EOE, IOE, Vital Signs
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Plaque index and home care
-Patient is aware of proper brushing technique and is still working on “hugging” not “snapping”
the floss when flossing
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Debridement of the mandible using magnetostrictive power inserts (XT Modified universal) then
followed by hand instrumentation
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Biofilm removal with toothbrush
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Fluoride treatment with Oral B Neutral Foam (2% sodium fluoride), 4 minutes.
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Treatment Plan
Re-evaluation
Summary
This periodontal case was definitely a personal challenge. He was my
first patient as a new second semester dental hygiene student. It was
a gratifying experience because I was involved with the learning
process with my patient. He presented with slight active chronic
periodontitis, which will hopefully not progress due to the patients
newly acquired knowledge of proper tooth brushing/flossing and
the impact of oral health systemically.
From this particular case I learned that Right and Left After Five
Modified inserts could have also been used for debridement. Not
only the XT modified, since the patient presented with light calculus
accumulation. When detecting calculus, I also have to remember the
contact area. I kept doubting myself when exploring and thought it
might have been residual calculus.