Nursing Perio Assignment

Periodontal Case Presentation

Medical Health History: 7/4/1952 ● Patient is a 72 year old female ● Patient has no known allergies ● Patient is taking multiple medications including

- Pravastatin Sodium - Metoprolol Succ ER - Allopurinol - Omeprazole - Amlodipine - Levocetirizine

PDR CATEGORIES Pravastatin Sodium To reduce elevated total cholesterol (total-C), LDL-C, apoB, and triglyceride levels, and to increase HDL-C in patients with primary hypercholesterolemia. PDR: Antilipemic Agent, HMG-CoA Reductase Inhibitor Contraindications: Hypersensitivity to pravastatin or any component of the formulation; active liver disease or decompensated cirrhosis Effects: Assess unusual presentations of muscle weakness or myopathy resulting from lipid therapy such as a patient having a difficult time brushing teeth or weakness with chewing.

Metoprolol Succ ER Angina, chronic stable: Long-term treatment of angina pectoris. PDR: Antianginal Agent; Antihypertensive; Beta-Blocker, Beta-1 Selective Contraindications: Hypersensitivity to metoprolol, any component of the formulation, or other beta-blockers; second- or third-degree heart block (except in patients with a functioning artificial pacemaker). Effects: Dysgeusia

Allopurinol PDR: Antigout Agent; Xanthine Oxidase Inhibitor Contraindications: Severe hypersensitivity reaction to allopurinol or any component of the formulation. Effects: No significant effects or complications reported

Omeprazole Gastroesophageal reflux disease, erosive or nonerosive (Rx only):

PDR: Proton Pump Inhibitor; Substituted Benzimidazole Contraindications: Hypersensitivity (eg, anaphylaxis, anaphylactic shock, angioedema, bronchospasm, acute tubulointerstitial nephritis, urticaria) to omeprazole, other substituted benzimidazole proton pump inhibitors, or any component of the formulation; concomitant use with products that contain rilpivirine. Effects:Taste perversion, dry mouth, esophageal candidiasis, and mucosal atrophy (tongue).

Amlodipine Hypertension, chronic PDR: Antianginal Agent; Antihypertensive; Calcium Channel Blocker; Calcium Channel Blocker, Dihydropyridine

Contraindications: Hypersensitivity to amlodipine or any component of the formulation. Effects: Gingival hyperplasia with amlodipine than with other calcium channel blockers (usually resolves upon discontinuation); consultation with a physician is suggested if gingival hyperplasia is observed. Orthostatic hypotension and erythema multiforme (severe oral ulcerations that respond well to systemic steroid therapy).

Levocetirizine Allergic rhinitis PDR: Histamine H1 Antagonist; Histamine H1 Antagonist, Second Generation; Piperazine Derivative Effects: No significant effects or complications reported Contraindications: Known hypersensitivity to levocetirizine, cetirizine, or any component of the formulation; end-stage renal disease (CrCl <10 mL/minute); hemodialysis; infants and children 6 months to 11 years of age with renal impairment

● Patient has hypertension ● The patient is not currently under medical treatment for any conditions,

syndromes, disorders, or ailments ● Patient is an ASA Class III due to having fluid around heart in over a year ago ● Medical Consult was signed and cleared by doctor, patient is fine and no

premedication needed ● Vital signs were taken on 10/24/24

● Blood Pressure: 117/67 (left) 125/66 (right) ● Pulse: 84 ● Temperature: 96.8 F ● Respiration: 16

● Patient weighs: 102 lbs

Dental History Patient has reported tooth extractions and a tooth that has fallen out over the years. Patient has not had a cleaning in years.

● Patient is missing: #1,3,4,5,12,13,14,15,17,18,19,26, 30,31,32 ● Last dental radiographs taken were a FMS taken on 10/28/2024, vertical

bitewings taken on 10/29/2024, and intraoral photos were taken 11/11/2024

Oral Inspection ● TMJ: clicking on right side, no pain when opening and closing ● Lymph nodes: bean shaped freely movable, right side noticeable ● Thyroid: normal swallowing, no abnormalities ● Skin & Lips: not chapped, brown, pigmented, moles on face, lower left vermillion

border (white macule) ● Oral Mucosa: linea alba bilaterally, adequate salivary flow ● Tongue: slightly coated, scalloped on lateral borders, pink ● Floor of the mouth: tori on the right side, adequate salivary flow, inadequate

lingual frenum attachment ● Hard palate: bilaterally tori upper left and right by molars (2 and 16), pigmented ● Soft palate: no lesions, pink ● Maxillary tuberosity: firm ● Tonsils: not swollen, pink ● Fauces: pink ● Retromolar areas: spongy, pigmented

Gingival description

Papillary Marginal Attached

Color Generalized

Localized

Pigmented

Pale pink: #23-24, #25-26

Pigmented

Pale pink: #23-24, 25-26 White stippled pecks above: #8,9,10

Pigmented

Contour Generalized

Localized

Bulbous Flat

Rolled #20-25

Adequate Width

Consistency Generalized

Localized

Soft Soft Bound firmly to underlying bone Flaccid: #2, 9-10, 20-21

Texture Generalized

Localized

Shiny Stippled Stippled

Size Generalized

Localized

Enlarged Enlarged Normal width

Position Generalized

Localized

Fills interproximal space Overfills interproximal: #6- 7,7-8,9-10,10-11 20-21,

At CEJ

Not at CEJ: #21-25 facial, 23-25 lingual

Hard tissue charting: 17 clinical crowns OHC: Class 3 Periodontal Classification: Severe perio

Abrasion/Abstraction None

Attrition Generalized

Denture None

Erosion None

Exudate None

Fractures that need Restorations None

Furcation None

Implants None

Incipient Caries/Carious Lesions None

Mesial Drifting None

Microfractures None

Missing Teeth #1,3,4,5,12,13,14,15,17,18, 19, 26, 30,31,32

Mobility 2 (2), 16 (2), 23 (2), 24 (2), 25 (2), 29 (2),

Amalgams 2 (O), 16 (DO)

Pockets 5mm or Greater Generalized

Recession #21-25 facial, 23-25 lingual

Gingival Index

Tooth # Mesial Facial Distal Lingual

3 1 1 1 1

9 1 1 1 1

12 1 1 1 1

19 1 1 1 1

25 1 1 1 2

28 1 1 1 1

Total: 6 6 6 7

Combined Total: 25 Total score/number of surfaces= Gingival Index 25/24= 1.04 GI (Mild Inflammation)

*Index is intended to access health status of gingival tissue only

Radiographic Evaluation

D= Distal M= Mesial

Tooth # Horizontal Vertical Tooth Horizontal Vertical

Bone Loss Bone Loss

# Bone Loss Bone Loss

1 9 D M

2 D M 10 D,M

3 11 D,M

4 12

5 13

6 D,M 14

7 D,M 15

8 D,M D (slight)

16 M

Tooth # Horizontal Bone Loss

Vertical Bone Loss

Tooth # Horizonta l Bone Loss

Vertical Bone Loss

25 D,M 17

26 18

27 D,M 19

28 D,M 20 D,M

29 D,M 21 D,M

30 22 M D

31 23 D M (slight)

32 24 D M (slight)

Tooth # Thickening of Lamina Dura

Widening of PDL

Tooth #

Thickening of Lamina Dura

Widening of PDL

1 9

2 10 D

3 11 M

4 12

5 13

6 M 14

7 D 15

8 16 M

Tooth # Thickening of Lamina Dura

Widening of PDL

Tooth # Thickening of Lamina Dura

Widening of PDL

25 M 17

26 18

27 D 19

28 20 M,D

29 21 D

30 22 D

31 23 M

32 24

Treatment Planning

TX1: Med/den Hx documented, pt has hypertension, take vitals,pt is a smoker but has not smoked in over a month (tobacco), ASA Classification III, FMS (20) taken, OI, hard and soft tissue charting started.

TX2: Review med/den Hx, take vitals, take Vertical BWs, finish OI, hard and soft tissue charting, complete OHC, fill out PCI form, then present PCI to for approval. D-severe perio, Class 3.

TX3: Med/den Hx reviewed, take vitals, proceed to take intraoral photos, impressions of maxillary and mandibular teeth, and pt. education. During pt.education I talked to patients about the importance of brushing twice a day with a soft toothbrush and flossing at least once a day. Explained their periodontal classification and the significance of seeing the dentist every 3-4 months.

TX4: Med/den Hx reviewed, take vitals, record plaque index and anesthetize prior to scaling. Patient is sensitive, therefore I would numb the patient with topical benzocaine 1-2 mins prior to injection. After topical I will anesthetize with 2% lidocaine 1:100,000 dilution to UR quadrant. I will do PSA and ASA injection for this quadrant. I will proceed with scaling the quadrant using a combination of the Cavitron and hand instruments, followed by root planing to ensure a thorough cleaning.

TX5: Med/den Hx reviewed, take vitals, record plaque index and anesthetize prior to scaling. Use topical then with 2% lidocaine inject 1:100,000 dilution to LR quadrant. I will do IA, Long Buccal, and Mental injection for this quadrant. I will proceed with scaling the quadrant using a combination of the Cavitron and hand instruments, followed by root planing to ensure a thorough cleaning.

TX6: Med/den Hx reviewed, take vitals, record plaque index and anesthetize prior to scaling. Patient is sensitive, therefore I would numb the patient with topical benzocaine 1-2 mins prior to injection. After topical I will anesthetize with 2% lidocaine 1:100,000 dilution to the UL quadrant. I will do PSA and ASA injection for this quadrant. I will proceed with scaling the quadrant using a combination of the Cavitron and hand instruments, followed by root planing to ensure a thorough cleaning.

TX7: Med/den Hx reviewed, take vitals, record plaque index and anesthetize prior to scaling. Patient is sensitive, therefore I would numb the patient with topical benzocaine 1-2 mins prior to injection. After topical I will anesthetize with 2% lidocaine 1:100,000 dilution to LL quadrant. I will do IA, Long Buccal, and Mental injection for this quadrant. I will proceed with scaling the quadrant using a combination of the Cavitron and hand instruments, followed by root planing to ensure a thorough cleaning. After scaling, I will polish the maxillary and mandibular arch with pumice, irrigate with chlorhexidine, and place Arestin in certain pockets. Refer patients to a periodontist, and place patients on a 3 month recall.

Lidocaine 1:100,000 ml Calculate the milligrams (mg) of solution in one cartridge

2% Lidocaine: 2 x10= 20 mg/mL of Lidocaine 20 x 1.8= 36 mg of anesthetic per cartridge

Calculate the patient's MRD in mg 102 lbs x 2 mg/lb = 204 mg

Convert MRD to cartridges 2% Lidocaine= 36 mg per cartridge MRD=204 mg of 2% Lidocaine for 102 lbs patient MRD / (number of mg/cartridge) 204/36= 5.6 cartridges

Prognosis The patient has a fair prognosis. Seeing the patient initially, the patient mentioned wanting to get all her teeth extracted, however; I explained to the patient that it would be beneficial to keep the teeth she has left as long as possible, opposed to having a complete denture. We talked about seeing the dentist and getting a cleaning every 3-4 months for optimal oral hygiene. I recommend her to see a periodontist due to the generalized severe bone loss she currently has.

Periodontal Case Presentation

Medical Health History: 7/4/1952 ● Patient is a 72 year old female ● Patient has no known allergies ● Patient is taking multiple medications including

- Pravastatin Sodium - Metoprolol Succ ER - Allopurinol - Omeprazole - Amlodipine - Levocetirizine

PDR CATEGORIES Pravastatin Sodium To reduce elevated total cholesterol (total-C), LDL-C, apoB, and triglyceride levels, and to increase HDL-C in patients with primary hypercholesterolemia. PDR: Antilipemic Agent, HMG-CoA Reductase Inhibitor Contraindications: Hypersensitivity to pravastatin or any component of the formulation; active liver disease or decompensated cirrhosis Effects: Assess unusual presentations of muscle weakness or myopathy resulting from lipid therapy such as a patient having a difficult time brushing teeth or weakness with chewing.

Metoprolol Succ ER Angina, chronic stable: Long-term treatment of angina pectoris. PDR: Antianginal Agent; Antihypertensive; Beta-Blocker, Beta-1 Selective Contraindications: Hypersensitivity to metoprolol, any component of the formulation, or other beta-blockers; second- or third-degree heart block (except in patients with a functioning artificial pacemaker). Effects: Dysgeusia

Allopurinol PDR: Antigout Agent; Xanthine Oxidase Inhibitor Contraindications: Severe hypersensitivity reaction to allopurinol or any component of the formulation. Effects: No significant effects or complications reported

Omeprazole Gastroesophageal reflux disease, erosive or nonerosive (Rx only):

PDR: Proton Pump Inhibitor; Substituted Benzimidazole Contraindications: Hypersensitivity (eg, anaphylaxis, anaphylactic shock, angioedema, bronchospasm, acute tubulointerstitial nephritis, urticaria) to omeprazole, other substituted benzimidazole proton pump inhibitors, or any component of the formulation; concomitant use with products that contain rilpivirine. Effects:Taste perversion, dry mouth, esophageal candidiasis, and mucosal atrophy (tongue).

Amlodipine Hypertension, chronic PDR: Antianginal Agent; Antihypertensive; Calcium Channel Blocker; Calcium Channel Blocker, Dihydropyridine

Contraindications: Hypersensitivity to amlodipine or any component of the formulation. Effects: Gingival hyperplasia with amlodipine than with other calcium channel blockers (usually resolves upon discontinuation); consultation with a physician is suggested if gingival hyperplasia is observed. Orthostatic hypotension and erythema multiforme (severe oral ulcerations that respond well to systemic steroid therapy).

Levocetirizine Allergic rhinitis PDR: Histamine H1 Antagonist; Histamine H1 Antagonist, Second Generation; Piperazine Derivative Effects: No significant effects or complications reported Contraindications: Known hypersensitivity to levocetirizine, cetirizine, or any component of the formulation; end-stage renal disease (CrCl <10 mL/minute); hemodialysis; infants and children 6 months to 11 years of age with renal impairment

● Patient has hypertension ● The patient is not currently under medical treatment for any conditions,

syndromes, disorders, or ailments ● Patient is an ASA Class III due to having fluid around heart in over a year ago ● Medical Consult was signed and cleared by doctor, patient is fine and no

premedication needed ● Vital signs were taken on 10/24/24

● Blood Pressure: 117/67 (left) 125/66 (right) ● Pulse: 84 ● Temperature: 96.8 F ● Respiration: 16

● Patient weighs: 102 lbs

Dental History Patient has reported tooth extractions and a tooth that has fallen out over the years. Patient has not had a cleaning in years.

● Patient is missing: #1,3,4,5,12,13,14,15,17,18,19,26, 30,31,32 ● Last dental radiographs taken were a FMS taken on 10/28/2024, vertical

bitewings taken on 10/29/2024, and intraoral photos were taken 11/11/2024

Oral Inspection ● TMJ: clicking on right side, no pain when opening and closing ● Lymph nodes: bean shaped freely movable, right side noticeable ● Thyroid: normal swallowing, no abnormalities ● Skin & Lips: not chapped, brown, pigmented, moles on face, lower left vermillion

border (white macule) ● Oral Mucosa: linea alba bilaterally, adequate salivary flow ● Tongue: slightly coated, scalloped on lateral borders, pink ● Floor of the mouth: tori on the right side, adequate salivary flow, inadequate

lingual frenum attachment ● Hard palate: bilaterally tori upper left and right by molars (2 and 16), pigmented ● Soft palate: no lesions, pink ● Maxillary tuberosity: firm ● Tonsils: not swollen, pink ● Fauces: pink ● Retromolar areas: spongy, pigmented

Gingival description

Papillary Marginal Attached

Color Generalized

Localized

Pigmented

Pale pink: #23-24, #25-26

Pigmented

Pale pink: #23-24, 25-26 White stippled pecks above: #8,9,10

Pigmented

Contour Generalized

Localized

Bulbous Flat

Rolled #20-25

Adequate Width

Consistency Generalized

Localized

Soft Soft Bound firmly to underlying bone Flaccid: #2, 9-10, 20-21

Texture Generalized

Localized

Shiny Stippled Stippled

Size Generalized

Localized

Enlarged Enlarged Normal width

Position Generalized

Localized

Fills interproximal space Overfills interproximal: #6- 7,7-8,9-10,10-11 20-21,

At CEJ

Not at CEJ: #21-25 facial, 23-25 lingual

Hard tissue charting: 17 clinical crowns OHC: Class 3 Periodontal Classification: Severe perio

Abrasion/Abstraction None

Attrition Generalized

Denture None

Erosion None

Exudate None

Fractures that need Restorations None

Furcation None

Implants None

Incipient Caries/Carious Lesions None

Mesial Drifting None

Microfractures None

Missing Teeth #1,3,4,5,12,13,14,15,17,18, 19, 26, 30,31,32

Mobility 2 (2), 16 (2), 23 (2), 24 (2), 25 (2), 29 (2),

Amalgams 2 (O), 16 (DO)

Pockets 5mm or Greater Generalized

Recession #21-25 facial, 23-25 lingual

Gingival Index

Tooth # Mesial Facial Distal Lingual

3 1 1 1 1

9 1 1 1 1

12 1 1 1 1

19 1 1 1 1

25 1 1 1 2

28 1 1 1 1

Total: 6 6 6 7

Combined Total: 25 Total score/number of surfaces= Gingival Index 25/24= 1.04 GI (Mild Inflammation)

*Index is intended to access health status of gingival tissue only

Radiographic Evaluation

D= Distal M= Mesial

Tooth # Horizontal Vertical Tooth Horizontal Vertical

Bone Loss Bone Loss

# Bone Loss Bone Loss

1 9 D M

2 D M 10 D,M

3 11 D,M

4 12

5 13

6 D,M 14

7 D,M 15

8 D,M D (slight)

16 M

Tooth # Horizontal Bone Loss

Vertical Bone Loss

Tooth # Horizonta l Bone Loss

Vertical Bone Loss

25 D,M 17

26 18

27 D,M 19

28 D,M 20 D,M

29 D,M 21 D,M

30 22 M D

31 23 D M (slight)

32 24 D M (slight)

Tooth # Thickening of Lamina Dura

Widening of PDL

Tooth #

Thickening of Lamina Dura

Widening of PDL

1 9

2 10 D

3 11 M

4 12

5 13

6 M 14

7 D 15

8 16 M

Tooth # Thickening of Lamina Dura

Widening of PDL

Tooth # Thickening of Lamina Dura

Widening of PDL

25 M 17

26 18

27 D 19

28 20 M,D

29 21 D

30 22 D

31 23 M

32 24

Treatment Planning

TX1: Med/den Hx documented, pt has hypertension, take vitals,pt is a smoker but has not smoked in over a month (tobacco), ASA Classification III, FMS (20) taken, OI, hard and soft tissue charting started.

TX2: Review med/den Hx, take vitals, take Vertical BWs, finish OI, hard and soft tissue charting, complete OHC, fill out PCI form, then present PCI to for approval. D-severe perio, Class 3.

TX3: Med/den Hx reviewed, take vitals, proceed to take intraoral photos, impressions of maxillary and mandibular teeth, and pt. education. During pt.education I talked to patients about the importance of brushing twice a day with a soft toothbrush and flossing at least once a day. Explained their periodontal classification and the significance of seeing the dentist every 3-4 months.

TX4: Med/den Hx reviewed, take vitals, record plaque index and anesthetize prior to scaling. Patient is sensitive, therefore I would numb the patient with topical benzocaine 1-2 mins prior to injection. After topical I will anesthetize with 2% lidocaine 1:100,000 dilution to UR quadrant. I will do PSA and ASA injection for this quadrant. I will proceed with scaling the quadrant using a combination of the Cavitron and hand instruments, followed by root planing to ensure a thorough cleaning.

TX5: Med/den Hx reviewed, take vitals, record plaque index and anesthetize prior to scaling. Use topical then with 2% lidocaine inject 1:100,000 dilution to LR quadrant. I will do IA, Long Buccal, and Mental injection for this quadrant. I will proceed with scaling the quadrant using a combination of the Cavitron and hand instruments, followed by root planing to ensure a thorough cleaning.

TX6: Med/den Hx reviewed, take vitals, record plaque index and anesthetize prior to scaling. Patient is sensitive, therefore I would numb the patient with topical benzocaine 1-2 mins prior to injection. After topical I will anesthetize with 2% lidocaine 1:100,000 dilution to the UL quadrant. I will do PSA and ASA injection for this quadrant. I will proceed with scaling the quadrant using a combination of the Cavitron and hand instruments, followed by root planing to ensure a thorough cleaning.

TX7: Med/den Hx reviewed, take vitals, record plaque index and anesthetize prior to scaling. Patient is sensitive, therefore I would numb the patient with topical benzocaine 1-2 mins prior to injection. After topical I will anesthetize with 2% lidocaine 1:100,000 dilution to LL quadrant. I will do IA, Long Buccal, and Mental injection for this quadrant. I will proceed with scaling the quadrant using a combination of the Cavitron and hand instruments, followed by root planing to ensure a thorough cleaning. After scaling, I will polish the maxillary and mandibular arch with pumice, irrigate with chlorhexidine, and place Arestin in certain pockets. Refer patients to a periodontist, and place patients on a 3 month recall.

Lidocaine 1:100,000 ml Calculate the milligrams (mg) of solution in one cartridge

2% Lidocaine: 2 x10= 20 mg/mL of Lidocaine 20 x 1.8= 36 mg of anesthetic per cartridge

Calculate the patient's MRD in mg 102 lbs x 2 mg/lb = 204 mg

Convert MRD to cartridges 2% Lidocaine= 36 mg per cartridge MRD=204 mg of 2% Lidocaine for 102 lbs patient MRD / (number of mg/cartridge) 204/36= 5.6 cartridges

Prognosis The patient has a fair prognosis. Seeing the patient initially, the patient mentioned wanting to get all her teeth extracted, however; I explained to the patient that it would be beneficial to keep the teeth she has left as long as possible, opposed to having a complete denture. We talked about seeing the dentist and getting a cleaning every 3-4 months for optimal oral hygiene. I recommend her to see a periodontist due to the generalized severe bone loss she currently has.