Case Study

Student Name: Student ADate: 10/22/2010

Patient: Earl E. Bird

Age: 56

Gender: Male

Height: 5’8”

Weight: 284 lbs

Vital Signs:

HR: 84Respiratory rate: 16Blood Pressure: 162/98 Temperature: 98.7 F

Chiefcomplaint

Tooth Sensitivity and Mobility, Need for cleaning and radiographs

MedicalAlert

Penicillin and Latex Allergy

Current Medications:Vasotec (high blood pressure)Aspirin (angina and coronary artery disease)Topomax (migraines)Albuterol (asthma)Lipitor (high cholesterol)

Summary of Medical History

The patient is under the care of a cardiologist for chronic angina and coronary artery disease, a neurologist for migraines, and a primary care physician for sleep apnea, high blood pressure, and high cholesterol. He has been prescribed Vasotec for high blood pressure, but forgets to take it. He has moderate asthma and severe headaches (migraines). He gets severe chest pains upon exertion. Mild exercise leaves him short of breath. He gets fever blisters when under stress. His mother has Type II diabetes. He was hospitalized last year due to chest pains. He smokes cigarettes and cigars on a daily basis. He consume 1-2 beers a day. He is allergic to penicillin and latex.

Dental History

The patient has not been to the dentist in over ten years. He has not made his dental health a priority, but is now having tooth sensitivity and mobility.

Social History and Story:

The patient has been working in a very stressful environment for the past eight years. He is a divorced father of two. Throughout the years, he has turned to smoking, eating, and drinking in an attempt to cope with stress. He has gained an immense amount of weight resulting in both high blood pressure and high cholesterol. He has been prescribed medications, but does not take them regularly. He is a cigar smoker and smokes about one pack of cigarettes each day. He enjoys smoking and has no desire to stop.

Due to the patient’s lifestyle, angina has become a recurring problem. He was recently diagnosed with Coronary Artery Disease. He has an appointment with his cardiologist next week to set up a plan for treatment.

Additional Notes

He exhibits black hairy tongue as well as nicotine stomatitis.

The patient has a difficult time getting around. He breathes heavily and perspires when walking short distances. He carries his inhaler with him at all times.

Radiographs

Bird, Earl E.

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Gingival Description and Areas of Recession: Maxillary

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Enter letters in blue for papilla (P) findings:K= Knife-likeBb= BulbousB= BluntedC= CrateredEd= EdematousS= Smooth & ShinyFb= Fibrotic, whiter

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Gingival Description and Areas of Recession: Mandibular

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Enter letters in red for cervical margin (CM) findings: F= FlatR= Rounded, rolledE= EnlargedCf= CleftedEd= EdematousS= Smooth & ShinyFb= Fibrotic

Enter letters in blue for papilla (P) findings:K= Knife-likeBb= BulbousB= BluntedC= CrateredEd= EdematousS= Smooth & ShinyFb= Fibrotic, whiter

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Pictures

Intraoral Pictures

Summary of Periodontal Status

Patient presents with signs of generalized moderate to severe periodontitis evidenced radiographically by severe bone loss in the anterior region and moderate bone loss in the posterior region. Furcation involvement is evident on numbers 3, 14, 18, 19 ,30, and 31. Class II mobility is evident clinically on numbers 8, 9, 23, 24, and 25. There is generalized recession of 1-3 mm. The JE has migrated apically, as determined by pocket depths of greater than 4 mm generalized. There is < 1 mm of attached gingiva on numbers 8, 9, and 23-25. There is also slight bleeding on probing generalized, and papillary redness and enlargement on the maxillary anterior lingual and mandibular anterior region. There are generalized rolled, blunted margins, fibrotic texture in posterior regions and maxillary anterior facial aspects, and smooth and shiny texture on the maxillary anterior lingual and mandibular anterior linguals. The consistency is firm on the maxillary facial and mandibular posterior, and soft on the maxillary anterior linguals.

Treatment Plan

1.Individual Oral Hygiene Instruction: Manual Brush, Modified Bass Technique, Floss, Perio-aid, End-tuft Brush, Tongue Scraper2.Nutritional Counseling3.Tobacco Cessation Counseling4.Radiographs5.Study Models6.4 Quadrants Definitive Debridement7.Selective Polish8.Local Anesthesia9.Fluoride- Professional Topical Application10.Referral to Periodontist11.3 Month Recall

Date Treatment Record

9/22/xxxx Health History Review, Vital Signs, EO/IO exam, CMX for Periodontal Evaluation, Dental Chart, Periodontal Assessment Quadrant I-IV, Treatment Plan, Plaque Index 85% , Patient Education with toothbrush and Modified Bass method, floss, and perio-aid, Tobacco Cessation Counseling- patient is interested but wants to wait a few weeks to discuss, impression for Study Model, NV: Quad I

9/29/xxxxHealth History Review, Vital Signs, EO/IO exam, Plaque Index 70%, Patient Education Review with toothbrush and Modified Bass method, floss, perio-aid, and tongue scraper, Nutritional Counseling, Definitive Debridement Quadrant I with ultrasonic and hand instruments, irrigation with Chlorhexidine, placed Arestin # 2,3. NV: Quad IV

10/6/xxxx Health History Review, Vital Signs, EO/IO exam, Periodontal Re-assessment Quadrant I, Plaque Index 65%, Patient Education introduction of power toothbrush due to patient’s difficulty with manual brush, Tobacco Cessation Counseling review with referral to Big Bend AHEC “Quit Smoking Now” program, Definitive Debridement Quadrant IV with ultrasonic and hand instruments, irrigation with Chlorhexidine, placed Arestin # 27, 30, 31, 32. NV: Quad II

10/13/xxxx Health History Review, Vital Signs, EO/IO, Periodontal Re-assessment Quadrant I and IV, Plaque Index 20%, Patient Education Review with power toothbrush , floss, and perio-aid dipped in Chlorhexidine, Nutritional Counseling review and referral to dietician for follow-up regarding dietary changes, Discussion about Tobacco referral- patient is going tomorrow for appointment with program counselor, Definitive Debridement Quadrant II with ultrasonic and hand instruments, irrigation with Chlorhexidine, placed Arestin # 14, 15. NV: Quad III

10/20/xxxx Health History Review, Vital Signs, EO/IO, Peridontal Re-assessment Quadrant I, II, and IV, Plaque Index 10%, Patient Education Review with power toothbrush, floss, perio-aid, and tongue scraper, Tobacco Counseling- patient is using Nicorette gum , Definitive Debridement Quadrant III with ultrasonic and hand instruments, irrigation with Chlorhexidine, placed Arestin #18, 19, 22. NV: Re-evaluation of all areas

11/25/xxxx Health History Review, Vital Signs, EO/IO, Periodontal Re-assessment all quads with referral to Periodontist, Plaque Index 12%, Patient Education Review with power toothbrush, perio-aid, and tongue scraper, Tobacco Counseling- patient is continuing with Big Bend AHEC “Quit Smoking Now” program, Definitive Debridement all Quads for removal of spicules and lavage with ultrasonic , irrigation with Chlorhexidine, Selective Polish, APF Fluoride treatment. NV: referral to periodontist and begin 3 month recare plan