Case Study

BY SARAH GRAHAM
DHY 220

Patient Summary
70

year old

Caucasian, female

Over

5 to 10 years
since last cleaning

Vital

Signs:

Blood

Pressure:
130/84

Heart

Rate: 82

Respiration

Rate: 26

Patient Summary cont.

Medical

History

Common Variable Immunodeficiency Anemia

Heart surgery for Atrial Fibrillation

TMJ surgery in 83 because of headaches and pain from

popping/clicking

Had surgery to fix crack in jaw from car accident in 80

Had biopsy of lung

Osteoarthritis

Medications

Azithromycin

Levofloxacin

500mg 3x/week

500mg

Taking for biopsy of lung

Premed for heart condition

Apixaban (Eliquis)

5mg 2x/day
Blood thinner, Nonvalvular
atrial fibrillation:To reduce
the risk of stroke and systemic
embolism in patients with
nonvalvular atrial fibrillation
(AF)

Sotalol

120mg 2x/day

Used to prevent atrial fibulation

900mg 3x/week

Antitubercular agent

Ethambutol

Side Effects of Medication

Nonselective

beta-blocker and may enhance

the pressor response to epinephrine, resulting
in hypertension and bradycardia

Bleeding

may occur after surgery

Common Variable Immunodeficiency

Anemia

disorder that impairs the immune system

highly susceptible to infection from bacteria, viruses and

often develop recurrent infections, particularly in the
lungs, sinuses, and ears

recurrent infections can lead to chronic lung disease

collections of inflammatory cells, called granulomas, can

be found in lungs, lymph nodes, liver, skin or other organs

Gastrointestinal complaints such as abdominal pain,

bloating, nausea, vomiting, diarrhea and weight loss are
not uncommon

Appointment #1

Medical

history reveled many conditions that contributed to pts special

condition

Extra/Intra oral exam showed heavy popping/clicking in pts left TMJ

with pain upon opening

Pt had TMJ surgery in 1983 due to harsh pain and migraines from TMJ
popping/clicking

Took FMX and PAN and found abnormal darkness in ramus of the
mandible

Had to refer pt to go have her jaw checked for Osteonecrosis and

needed physicians consent from her heart and immuno Physician
before I could continue treatment

Gave 3 day nutritional survey to complete

Panoramic

Full Mouth Series

Dentition Charting

Appointment #2

Couldnt get pt back in until about 4mo later because

pt kept getting bronchitis

Pt did not have necrosis in her jaw

She had trouble keeping her mouth open for long

periods of time

Pt had posterior mandibular molars removed when

she was very young

She presented with attrition and slight possible

erosion from her condition

Perio chart

Perio Assessment
No
Pt

deep pocket depths

is anemic so slight pallor in gingiva

Low

BOP

Papilla
AAP

was blunt and basically flat in the anterior

class I

WSCC

prophy class I

Anterior teeth

Posterior Max teeth

Appointment #2 cont.
Scaled
Pt

All

had slight bleeding upon scaling

Polished
Oral

with Clinpro

Irrigated with Chlorahexidine

Used

Varnish Fluoride

Went

over nutritional Evaluation

Nutritional Evaluation
High

carb and protein

intake

Low

fluid intake

Conclusion

SPT: 6MO

Stressed importance of having more variety of foods in diet

and increasing intake of more water

GI and PI were WNL but reminded pt to make sure to

floss once a day

Ask pt to try to use a tongue scraper or brush tongue

when she is feeling well enough

References

http://primaryimmune.org/about-primary-immunodeficiencies/specificdisease-types/common-variable-immune-deficiency
/

http://ghr.nlm.nih.gov/condition/common-variable-immune-deficiency

http://online.lexi.com/lco/action/doc/retrieve/docid/dental_f/2074422