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Periodontal Disease Patient Profile Patient is a 68 year old male Health History Dental History Last dental visit was in January 2014 Presents with High Blood pressure Orthodontics 55 years ago Medications: allertec and ¼ grain aspirin, multivitamin Extracted wisdom teeth 50 years ago Congenital heart defect, no per-medication required Occasional canker sores Allergies to dust, mold, feathers, ragweed and gluten Flosses once a day History of arthritis Allergy to Penicillin=causes rash Electric toothbrush once a day ASA III Extra and Intra Oral Exam Findings HEAD, NECK: 4 mm round brown mole behind left ear. LIPS: fordyce granules. MUCOSA: linea alba. varicosities in the corner of the mouth. PALATE: high vaulted palate FAUCES (TONSILS, PHARYNX): Fauces red . pt states it is due to post nasal drip. tonsils absent. TONGUE:coated Dental Exam Findings Intrinsic stain: amalgam #14 Occlusion: Attrition: generalized slight attrition on anterior Molar right: Class I Abrasion: generalized abrasion Canine right: class I Calcification: tooth #7 around a restoration Canine left → Class II Overbite: coronal 1/3 slight Over jet: 4 mm Labio/linguoversion: mild labioversion #21 & 25. Mild linguoversion #22 & 27. Crowding of all anteriors Molar Left: Class I Caries risk factors: previous restorations Oral Habits: bruxism Intra Oral Photographs Intraoral Photographs Intraoral Photographs Intraoral Photographs Dental Chart Periodontal Chart Periodontal Evaluation Assessment Findings Class I furcation tooth #31 Mucogingival involvement: #12, 20, 21, 22, 23, 25, 26, 27, 29 Bleeding on probing: #2, 4, 5, 12, 21, 23 & 27 Periodontal risk factors: stress Periodontal contributory factors: calculus, faulty restorations, food impaction, position of teeth/malocclusion, and history of orthodontics Biofilm index: 56% Soft deposit generalized slight on the cervical 1/3 Extrinsic stain generalized moderate pits, fissures, and linguals of mandible Generalized ledges of supra and subgingival calculus Gingival Description Maxilla is generalized pink, spongy, rounded, slightly edematous margins with localized redness #3, 8 & 12 with localized stippled, fibrotic with overlying edematous tissue on the anteriors. Mandible is generalized marginal redness, rolled, shiny, spongy, edematous tissue with McCall's Festoons on #4, 5, 21 & 28. Radiographs Radiographic findings #31 & 18 20% bone loss. Films are dark and hard to read. Date of radiographs 4/10/12 Periodontal Diagnosis Generalized moderate active chronic periodontitis AAP Case Type: III Treatment Plan Procedures First visit: Reviewed and updated medical history Sent medical consult regarding high blood pressure Performed extraoral exam and intraoral exam. Started Dental chart Second visit: Reviewed medical history Cursory Extra/intraoral exam. Finished dental charting Started periodontal charting Procedures Third visit: Fourth visit; Medical history reviewed Medical history reviewed Cursory Extra/intraoral exam Cursory Extra/intraoral exam Continued to work on periodontal charting Finished periodontal charting Photos taken for periodontal project Received FMX from 4/12 Procedures Fifth visit: Medical history reviewed Cursory Extra/intraoral exam Finished periodontal assessment Performed deposit assessment Bio film index 56% Completed treatment plan Debridment: started power driven maxillary right Bio film removal: tooth brush method & interproximal brush Procedures Sixth visit: Seventh visit: Medical history reviewed Medical History: reviewed Cursory EOE & IOE Cursory EOE & IOE Biofilm index: 50% Debridment: hand instrumentation on maxillary right and anterior sextant Debridment: power instumentation maxillary left sextant and mandible Other Dental Hygiene Services: Reviewed oral Home care Soft deposit: tooth brush, selective polish and floss Applied 5% NaFl varnish DH report was given to patient Summary It was difficult to assess this patient due to my inexperience and the extended time in between patient visits. I would have liked to reevaluate him to see if my probing depths were accurate from the first time. The patient will not let me retake pictures and will not come back for re-evaluation I still believe this patient to have generalized active chronic periodontitis.