Case Study
Student Name: Student A
Date: 10/22/2010
Patient:
Earl E. Bird
Age:
56
Gender:
Male
Height:
5’8”
Weight:
284 lbs
Vital
Signs:
HR: 84
Respiratory rate: 16
Blood Pressure: 162/98
Temperature: 98.7 F
Chief
complaint
Tooth Sensitivity and Mobility, Need for
cleaning and radiographs
Medical
Alert
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.
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.
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.
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.
Right
434
446
644
434
434
344
567
987
976
674
433
434
434
435
534
434
V
434
456
654
444
434
344
567
987
976
654
434
434
334
445
534
434
434
454
454
434
434
444
445
767
654
444
544
434
434
454
454
434
445
545
555
444
434
445
545
767
655
544
544
434
434
Gingival Description and Areas of Recession: Maxillary
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
C
M
P
C
M
P
C
M
P
C P
M
C P
M
C P
M
C P
M
C
M
P
C
M
P
C
M
P
C
M
P C
M
P C
M
P
C
M
P C
M
P
C
M
R
F
b
B
b
B
F
b
R
F
b
B
b
B
F
b
R
Fb
B
b
B
F
b
R
F
b
R
F
b
R
F
b
R
F
b
R
F
b
B
b
B
F
b
R
F
b
B
b
B
F
b
R
F
b
B
b
B
F
b
R
F
b
B R
b F
B b
F
b
B R
b F
B b
F
b
B
b
B
F
b
R
F
b
B R
b F
B b
F
b
B
b
B
F
b
R
F
b
2
1
1
3
3
1
B
b
B
F
b
1
1
1
2
B
b
B
F
b
B
b
B
F
b
2
2
Enter letters in red for cervical margin (CM) findings:
F= Flat
R= Rounded, rolled
E= Enlarged
Cf= Clefted
Ed= Edematous
S= Smooth & Shiny
Fb= Fibrotic
3
B
b
B
F
b
2
3
3
3
3
1
1
1
1
1
2
1
1
1
1
Enter letters in blue for papilla (P) findings:
K= Knife-like
Bb= Bulbous
B= Blunted
C= Cratered
Ed= Edematous
S= Smooth & Shiny
Fb= Fibrotic, whiter
Gingival Description and Areas of
Recession: Mandibular
3
1
2
1
2
2
2
2
2
1
B
b
B
E
d
S
R
E
d
S
B R
b E
d
B S
E
d
S
B
b
B
E
d
S
C P
M
C
M
P
C
M
P C
M
P C
M
P C
M
P C
M
2
8
27
25
24
23
22
R
Ed
S
B
F
b
R
E
d
S
B
F
b
R
E
d
S
C
M
P
C
M
P
C
M
P
C
M
P
B
b
B
E
d
S
Enter letters in red for cervical margin (CM) findings:
F= Flat
R= Rounded, rolled
E= Enlarged
Cf= Clefted
Ed= Edematous
S= Smooth & Shiny
Fb= Fibrotic
2
6
1
1
B R
b Ed
B S
E
d
S
B
F
b
29
2
2
R
E
d
S
R
E
d
S
30
2
B
b
B
E
d
S
B
F
b
31
2
2
R
Ed
S
R
E
d
S
32
2
R
E
d
S
1
1
2
1
3
B
F
b
R
F
b
B R
F F
b b
B R
F F
b b
B
F
b
P
C
M
P C
M
P C
M
P
21
20
19
Enter letters in blue for papilla (P) findings:
K= Knife-like
Bb= Bulbous
B= Blunted
C= Cratered
Ed= Edematous
S= Smooth & Shiny
Fb= Fibrotic, whiter
R
F
b
C
M
18
B
F
b
R
Fb
P
C
M
17
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
Scraper
2.Nutritional Counseling
3.Tobacco Cessation Counseling
4.Radiographs
5.Study Models
6.4 Quadrants Definitive Debridement
7.Selective Polish
8.Local Anesthesia
9.Fluoride- Professional Topical Application
10.Referral to Periodontist
11.3 Month Recall
Date
9/22/xxxx
9/29/xxxx
Treatment Record
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
Health 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 Counselingpatient 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