RDH 2810

PATIENT CASE PRESENTATION

PATIENT PROFILE: Mr. G is a 47-year-old Hispanic male. He is a new resident of TN and is

originally from Mexico. He visited South College Clinic for a cleaning.
MEDICAL HISTORY SUMMARY: Mr. G reports no diagnosed medical conditions. However, he
presented with hypertension at all his visits.
The patient takes no prescribed medications at the current time and reports no allergies.
VITALS
BP: 137/80 mmHg. Hypertension Stage I
PR: 85 bpm, strong and regular

RR: 16 bpm, easy and regular

O2: 96%
TEMP: 93.2 F
SUMMARY OF HEALTH
The patient is a 47-year-old Hispanic male with uncontrolled hypertension. No medications or
allergies to note.
PAST DENTAL HISTORY: The patient was seen by a dentist in Mexico over 2 years ago to have
restorations completed. He has not been to a dentist since.
CHIEF COMPLAINT: Mr. G came to the dental hygiene clinic for cleaning.

CLINICAL FINDINGS:
Extraoral examination: The patient presents with facial symmetry. No palpable lymph nodes.

Radiographic findings: Generalized Horizontal bone loss is present on all mandibular and
maxillary teeth. Caries were detected on the buccal of tooth #16. Mandibular Impacted
supernumerary tooth.
Intraoral examination: Mandibular left tori present. Teeth #6 & #11 had buccal fractures, and
buccal caries were detected on tooth #16.

Caries Risk Assessment: Moderate. The patient has visible plaque and snacks constantly
throughout the day.

Gingival Assessment: Generalized dark pink gingival color noted. Bulbous papilla localized to
mandibular incisors. Melanin pigmentation is present above teeth #4, #5, & #6. Operculum
present above tooth #32

Periodontal examination: The patient presented with periodontitis. Calculus is heavy and
generalized throughout the mouth.

Periodontal Assessment
DENTAL HYGIENE DIAGNOSIS:
Radiographic loss of attachment is interdentally present in all quadrants. Probing depths range
from 4-9 mm with bleeding present.
The patient presents with Stage 2 Grade A periodontitis.
DENTAL-HEALTH EDUCATION:
Plaque Control Record: 38%
The patient brushes his teeth twice a day but only flosses when he remembers. The STILLMANS
technique was recommended twice daily along with interdental flossing. Instructed the patient
to use a cee saw motion when flossing and to reach below gum line until resistance is felt.
PLANNING:
Rationale for case selection:
Due to the attachment loss, depth of periodontal pockets, radiographic bone loss, and evidence
of active disease, Non-Surgical Periodontal Therapy was planned to be administered in all
quadrants. Anesthesia is to be used for instrumentation.

Goals:
1. Improve oral hygiene habits. Encourage the patient to implement flossing regularly.
2. Remove all biofilm as well as calculus deposits.
3. Bring the patient to health and stabilize the disease.
4. Reduce the depth of periodontal pockets.
5. Encourage the patient to continue his planned care visits.
Initial treatment plan:
Appointment 1:
Medical and dental history; intraoral, extraoral examination
Complete series of radiographs; gingival assessment, periodontal probing; calculus detection;
Appointment 2:
Comprehensive exam
Treatment plan proposal and acceptance
Oral Hygiene Instruction: Emphasis on flossing technique/encouraged electric toothbrush.
Perform local anesthesia administration to Quadrant 4
Complete debridement of quad 4 with powered and hand instrumentation

Appointment 3:
Oral Hygiene Instruction: Emphasis on flossing technique
Perform local anesthesia administration to Quadrant 1
Complete debridement of quad 1 with powered and hand instrumentation

Appointment 4:
Oral Hygiene Instruction: Emphasis on flossing technique/Discussed improvement of plaque
score.
Perform local anesthesia administration to Quadrant 2
Complete debridement of quad 2 with powered and hand instrumentation

Appointment 5:
Oral Hygiene Instruction: Emphasis on flossing technique.
Perform local anesthesia administration to Quadrant 3
Complete debridement of quad 3 with powered and hand instrumentation

Appointment 6:
Periodontal Re-Evaluation
Oral Hygiene Instructions: review oral hygiene care
Retreatment was not necessary.

Appointment 7: Recare visits at 3-month intervals planned

IMPLEMENTATION: Treatment proceeded as planned. The patient verbalized willingness to
make changes to improve oral health. The patient did not report discomfort during the delivery
of local anesthetics. The plaque index decreased steadily after 3rd appointment. Hygiene
procedures were completed with minimum difficulty.
Appointment 6:
Vitals and Review of medical history completed. The patient presented again with
hypertension. No new significant findings during EO/IO exam. Periodontal probing and calculus
detection were re-evaluated after completion.
EVALUATION: Mr.G was treated in the dental hygiene clinic for a period of 4 months. The re-
evaluation assessments indicate that treatment helped make improvements to patients’ status.
There was a reduction in some probing depths. Deeper pocket depths were localized to areas
surrounding 3rd molars. Gingival tissue improvements.
The patient was able to demonstrate proper technique for brushing. There has also been an
improvement in Mr. G’s flossing technique. The final Plaque control record was 28%.
RESULTS:

Mr. G responded well to Nonsurgical Periodontal Therapy. There was an improvement in the
appearance of tissue. There was also some pocket depth reduction. There was a large
improvement in his Oral Hygiene techniques.
Mr. G will continue with the restorative treatment planned and is scheduled for 3 month recall
periodontal maintenances.