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DEH 23 Periodontal Case Natalie Buzard Riverside Community College Patient Profile 32 year old, married Medical History white male Childhood Vaccine- 6-7 Hep. B-1996, no titer Chief Complaint- “to Outpatient shoulder get my teeth cleaned.” surgery- 7/07 Dental HistoryPerkacet for 1 week for Ortho- 1990-1992 No current appliances Grinds at night-no pain Cleaning & DDS-7/07 FMX 11/07 at RCC pain after surgery 7/07 No other Medications Clinical Findings- E&I exam E: 6mm scar below lip, 15mm and 30mm scar on left side of neck- pt. visited dermatologist in 2006- abnormal collagen synthesis and extremely sensitive skin. I: bilateral mandibular tori, palatal torus, bilateral linea alba, bilateral Fordyce granules, 2mm lip bite on labial mucosa between #8 & 9, keratinization on buccal mucosa at occlusal plane due to cheek biting. Periodontal Evaluation Assessments: Gingival Des: Free: Gen PSFS, Loc red, edematous, bulbous and shiny Attach: Gen PFS Loc red on ant. Mandibular teeth MBI: 12.5% BOP: 14.3% with gen. probing depth of 2-3, loc. 4 on M31 and M15 Recession- 1mm on Mobility: + on 6-11, 26-23 Fremitus: + on 7-9 Furcations: None RCC Calculus Code: Light/Medium Radiographic Findings Missing 1,16,17 &32 due Periodontal: to extraction at age 20. trabecular pattern Restor:3-C-DO, 14-A-O, consistent throughout 15-C-O, 19-C-O, 20-C-O, Lamina dura- present 21-C-O, 22-C-IL, 28-C-O, and consistent 29-C-O, 30-C-DO, 31Cthroughout MO PDL space- present Tooth findings: cal on M15, and consistent st dilaceration of mand. 1 throughout molars Alveolar crest-1-2 mm No abnormal osseous below CEJ throughout findings ADA and AAP ADA: I AAP: Slight Gingivitis due to plaque and calculus RCC Calculus Code: Light/medium Rationale for Selection: Compliant Patient with Light/Medium Calculus Dental Health Education Patient flosses 1x per week Taught “C” flossing technique Encouraged patient to floss 3x per week Patient brushes daily Taught Bass Brushing Technique Encourage pt. to brush at least 2x per day Goals and Treatment Plan Goals Reduce BOP to 7% Increase flossing to 3x/week Treatment Plan Appt 1- Assessments, DDS exam Appt 2- 2nd check-in, OHI, PI, ULQ Appt 3, LLQ, URQ, LRQ, selective polishL#27&L#25, fluoride Appt 4- 4 mos. recare Periodontal Project- Pictures Before After