PATIENT PROFILE: X is a 36-year-old Caucasian woman from Murfreesboro, TN.

X came to the
clinic originally for a rou ne cleaning with a chief complaint of generalized sensi vity.
MEDICAL HISTORY SUMMARY: X presented with seasonal allergies for which she takes Clari n
10 mg once daily (side e ects include dry mouth, mild stomach upset, trouble sleeping,
dizziness, headache, nervousness, loss of appe te, or thirst may occur) and Flu casone
propionate (side e ects may include headache, dryness, s nging, burning or irrita on in the
nose, nausea, vomi ng, diarrhea, bloody mucus in nose, dizziness) as needed.
Vitals remained in good range with each appointment with the excep on of elevated blood
pressure due to anxiety of injec ons on one occasion.
No other medical history was disclosed.
VITALS
BP: 118/78 mm Hg strong regular right arm
PR: 66 bpm
RR: 14 rpm, non labored and strong
O2: 98%
TEMP: 97.6 F
SUMMARY OF HEALTH
The pa ent is a 36-year-old female who has seasonal allergies and takes Flu casone propionate
and Clari n to treat. ASA 2 vitals within normal limits. No other medical history was noted.
PAST DENTAL HISTORY: The pa ent moved and has not been able to nd a dental home in a
new city. The last dental appointment was several years prior.
CHIEF COMPLAINT: X complained of dental sensi vity.
CLINICAL FINDINGS:
Extraoral examina on: There were no palpable ndings. The gate was regular and hair line
intact. Bilateral lobe piercings, and sca ered ephelides present.

Radiographic ndings: Horizontal bone loss within coronal third and radiographic calculus. #1
impacted and a watch was placed for possible extrac on. A watch was placed on 32 for possible
extrac on.

ti
ti

ti

fi
ff
ti
ti

ti
ff
ti
ti

tt

ti
fi

ti
ti

ti

fi
ti
ti

ti
ti
ti

ti
 Intraoral examina on: cheek bite trauma posterior #18. The palate is vaulted with mandibular
tori. The tongue was white coated. The salivary ow was free- owing. Frenums were intact.
Tonsils present.

Caries Risk Assessment: Moderate. X does not have a dental home and drinks lemon water
throughout the day.

Gingival Assessment: The gingiva presented coral pink and t snuggly. The margin posi on was
1-2 mm coronal to CEJ. The margin shape was at and the papilla shape was pyramidal and t
snugly. The texture was s ppled and the consistency was rm. Localized Gingival ndings were a
red mark above #25, recession on 4 5 6 11 15 18-22 26-31, localized bulbous anterior
mandibular, and red in color.

Periodontal examina on:

ti

ti
ti

fl

fl
fi
fi
fl
fi
ti
fi

 DENTAL HYGIENE DIAGNOSIS:

With horizontal bone loss and radiographic calculus, the pa ent was diagnosed with
Periodon s (Stage 1 Grade B) and localized plaque-induced gingivi s. NSPT all four quads with
local anesthesia was presented as treatment plan.
DENTAL-HEALTH EDUCATION:
Plaque Control Record: rst appointment: 65%; second appointment: 20.6%; third appointment:
6%
X was recommended the Bass modi ed bass method in posteriors and S llman for mandibular
anterior where gingivi s presented. A water pic was also recommended.
X was advised to use Sensodyne to alleviate sensi vity and to stop drinking lemon water
throughout out day.

PLANNING:
Ra onale for case selec on:
Because of the nature of the loss of a achment and bone level, the depth of the

ti

ti
ti

ti
ti
fi

fi
tt

ti

ti
ti
ti

 periodontal pockets, and calculus deposits, the pa ent will bene t from NSPT with local
anesthesia. Once implemen ng new oral hygiene instruc ons with at-home care, the pa ent
should respond well to treatment and have a great prognosis.

Goals:
1. Improve the health of pa ent X’s gingiva and periodon um

2. Using ultrasonics and hand instruments, remove all bio lm and calculus
3. Teach X how to properly maintain healthy gingiva and prevent calculus using at-home skills
and instruments and prac ce be er nutri on
4. Reduce the depth of periodontal pockets.
5. Encourage X to nd a dental home and establish 3 month re-care appointments to maintain
oral health
Ini al treatment plan:
Appointment 1:
X lled out medical and dental history; intraoral, and extraoral examina ons were given. FMX
and panoramic taken. Calculus detec on and perio char ng completed.

Appointment 2:
Oral hygiene instruc on was presented and assessed. Comprehensive doctor's exam completed.
Treatment plan made and signed.

Appointment 3:
Local anesthesia (IANB and long buccal) using Lidocaine 2% was given. Quad 4 debrided
Appointment 4:
Local anesthesia (PSA, ASA, IANB, and long buccal) using Lidocaine 2% were given. Quads 2 and
3 debrided.

Appointment 5: Local anesthesia (PSA and ASA) using Lidocaine 2% were given. Quad 1
debrided.
Appointment 6: 3 month re care.
IMPLEMENTATION:
The treatment went as planned. X had anxiety over injec ons and wore headphones to help
ease her anxiety. X responded well to LA and NSPT. X was able to see oral health levels improve

fi
ti

fi
ti

ti
ti
ti
tt

ti
ti

ti
ti
ti
ti
ti
fi

fi
ti

ti
 as treatment progressed. X was able to demonstrate knowledge of new oral hygiene habits at
home.

Treatment revisions:
No treatment revisions were necessary.
EVALUATION:
X presents for her 3 month re care on September 12th.