Periodontal Case Classification

November 12th 2024

1:00pm

· Patient is a 67 year old, African American woman.

· Patient has no known allergies to any drugs, food, latex or pollen

· In 2016, the patient was hospitalized for five days for fibroids surgery.

· The patient is not currently under any medical treatment for any conditions, syndromes, disorders or ailments.

· Patient is an ASA class 1

· Vital Signs were taken on October 24th 2024

· Blood Pressure: Right arm: 128/71 Left arm: 125/73

· Pulse: 68 bpm

· Temperature: 97.5

· Respiration: 18bpm

· Patient has had a few teeth extracted over the years. The patient does not have any discomfort in her mouth. Patient Maryland bridge that she had placed at 21 years old came off on 10/17/14. On 11/6/24 the patient went to the doctors to get a temporary crown placed on tooth #2.

· Last dental radiographs taken were a FMS on 10/24//2024 along with vertical bitewings on 11/7/2024 and intraoral photos.

· Pt is missing tooth #’s 1,7,8,14,16,18, and 30. None have been replaced

Oral Inspection

· TMJ: grinding when opening and closing bilaterally, Patient stated that there is pain occasionally on the left side when opening and closing but not currently experiencing pain or tenderness

· Lymph nodes: bean shaped, freely moveable, no pain or tenderness

· Thyroid: freely moveable when swallowing

· Skin and lips: Smooth, intact, even in color, unilaterally right side vermillion zone is sunk in because of missing #7 and #8 (facial collapse).

· Oral mucosa: Linea alba bilaterally, pink and keratinized, less than 1mm lesion on unilaterally right side that is red in color, buccal mucosa has a swollen (gummy appearance)

· Tongue: Dorsal surface slightly coated white, lateral border is scalloped, patient presents with a tongue thrust

· Floor of mouth: Sublingual frenulum present, adequate salivary flow, no lesions, mandibular torus present highly prominent on unilaterally right side , adequate lingual frenum attachment coral pink

· Hard palate: Smooth, pink, firmly attached to bone, high vault, very slight petechiae present

· Soft palate: no lesions, smooth, pink in color

· Maxillary tuberosity: firm, pink in color

· Tonsils: Present, Unilaterally right side is slightly red and enlarged red

· Retromolar areas: spongy, keratinized, white/purple in color unilaterally left side, 3rd molars are present

· Occlusion: Bilaterally Class 1(canine relationship)

· Overjet: 3mm

· Overbite: Slight- incisal one third

· Midline: Deviated to the right 3mm

Gingival Description

Hard Tissue Charting: 25 Clinical Crowns

Widening of the PDL-

Thickening of the Lamina Dura-

Gingival Index

37/24=1.54 GI (Moderate Inflammation)

total/# of surfaces=gingival index

Exudate- patient presents with no exudate

Mobility- Tooth number #26,25,24 1mm involvement

Pocket Formation- Patient presents with pockets greater than 4mm on 22 surfaces

Radiographic Findings

Treatment 1: Patient came in on 10/24/2024. Medical and dental history was documented. Recorded all vital signs. Blood pressure was as follows: right arm :128/71, left arm:125/73, pulse- 68 bpm, respiration 18, temp-97.5. The patient had no significant medical concerns but she stated that she underwent surgery for fibroids in June of 2016 and was hospitalized for five days. The patient stated she recently went to the dentist 1 month ago because her Maryland bridge had fallen out. Pt has a history of asthma at the age of 6 years old but it has been dormant for over a century. Patient is an ASA classification 1. The patient's last dental radiographs were from May 27 2022, the patient was due for an updated radiographic evaluation. Exposed a Digital Full Mouth Series using 18 films. As I was exposing the patient I noticed radiographic bone loss and explained it to her.

Treatment 3: Reviewed medical and dental history, there were no changes. Evaluated patients vital signs respiration was 16 bpm, temp-97.7. Revaluated all findings and filled in the PCI approval form and presented PCI. Patient was approved to proceed with intraoral photos. Pt OHC was taken and determined she was a class III. Scheduled patient for follow up appointment. Patient was dismissed.

Treatment 4: Reviewed medical dental history patient presented with no changes.Patients maxillary arch and mandibular arch impressions were taken but there was no gypsum yellowstone in the clinic. Patient impressions were taken with alginot and wrapped to be poured for evaluation when stone is available. Discussed the importance of homecare and went over patient education. Scheduled periodontal consultation with the dentist and patient dismissal.

Treatment 5:

Medical and dental history review. Reevaluate patients progress from recommendations during patient education and reiterate how to improve. Take the patient's blood pressure and document it in clinical notes. Apply Benzocaine 20% topically to dried intraoral tissues at injection sites for 1-2 minutes. Administer local anesthetics to the right side, both maxillary and mandibular. Since there are no contraindications, I will be using Lidocaine 2% 1/100,000. Complete scaling on the right side. Complete root planning on pockets 4mm or greater such as: Facial #'s 2D, 4DL, 5M, 9M,12D, 17MCD, 19CM,28M,32DM. Polish with pumice, irrigate with chlorhexidine. Schedule patient for the next appointment. Dismiss patient

Treatment 6:

Medical and dental history review. Reevaluate patients progress from recommendations during patient education and reiterate how to improve. Place arestin in 5mm or greater pockets, enforce good oral hygiene home care. Schedule patient to come back in 2-3 months, reevaluate patient checking for areas that arestin was placed and enforce home care.

Patient MRD for Local Anesthesia

Healthy patient ASA I classification, 170lbs

1.7ml Lidocaine 2% w/epinephrine 1:100,000 3.2mg/lb

2% lidocaine 2 x 10= 20 mg/ml

20 x 1.7 = 34 mg per cartridge

MRD is 300 mg per appointment

170lbs x 2 mg/lb lidocaine = 340 mg (over MRD)

340/34 = 10 Cartridges

300/34 = 8.8 Cartridges

Epinephrine

1: 100,000 epi in 2% lidocaine 1.7 solution

1000/ 100,000= 0.01 ml

1.7 ml x 0.01 =0.017 mg epi per cartridge

Healthy pt =0.2 mg

0.2 mg/ 0.017 = 11.7 cartridges

Limiting dose of of lidocaine is 8 cartridges

Prognosis

The patient is highly motivated to improve her oral health and demonstrates good homecare practices. She is actively engaged in her treatment, working collaboratively with me as a co-therapist, which supports a favorable prognosis. She has committed to regular dental visits to maintain our progress, manage her periodontal disease, and reduce her caries risk by controlling plaque levels. The referrals and oral hygiene education provided have been beneficial, and she and I are confident that, together, we can sustain her oral health.