PATIENT CASE PRESENTATION
MACKENZIE WHITLEY
• This patient is a 71-year-old White female. She is married
and she has been retired for about 10 years now. She
sometimes works part time at her previous job when
needed.
PATIENT
• This patient has a dental home and is aware that she has
PROFILE periodontal disease. She alternates going to her dentist
and periodontist every 3 months.
MEDICAL HISTORY SUMMARY
• No reported medical conditions. • Additional Information
• Allergies • This patient is hard of hearing, so she does
• Codeine – nausea/vomiting have hearing aids.
• Penicillin – hives • The patient reports she had a bone graft
• Sulfa drugs – hives surgery completed due to the amount of
• Medications
vertical bone loss present at her periodontist
• Trazodone (100mg)
office approximately 2 years ago in 2021. The
• Sleep trouble
patient is not sure if the graft was completed
• Adverse effects – dizziness, xerostomia, dysgeusia
on UR or the LL.
• Fish Oil (1200mg)
• Daily health maintenance and benefits
VITALS
1st and 2nd appointment – Periodontal Maintenance
3rd appointment – Periodontal Maintenance Re-care
VITALS
4th & 5th appointment - NSPT
6th appointment – NSPT Re-eval
DENTAL HIST ORY
• Patient reported a history of periodontal disease, she alternates visiting her
periodontist and dentist every 3 months. She reported having a bone graft
procedure 2 years ago to hopefully restore the bone loss in the area. The patient
didn’t remember if the graft was done on the UR or LL quad.
• This patient had #17 and #32 extracted, but #1 and #16 are unerupted.
• This patient has 7 crowns, 4 amalgam restorations, and 7 composite
restorations.
CHIEF COMPLAINTS
• This patient was treated at South College Dental Clinic a total of 6 times. The
first visit was a periodontal maintenance. At this appointment, the patient
reported no problems or discomfort.
• The second appointment was the 3-month periodontal maintenance re-care. At
this visit the patient reported localized sensitivity of the gingival tissue
surrounding #31.
• At the subsequent appointments, the patient did not have any chief complaints.
She reported no problems or discomfort.
• However, at her final appointment, the NSPT re-eval, she reported she felt as if
something was “stuck” in between her teeth on the LR quad and she was
experiencing some discomfort.
CLINICAL FINDINGS: EO
EXAMINATION
• Extraoral Exam
• Gait: Normal, no limp.
• Face/head/neck: Bilateral ear piercings, even distribution of hair growth, face is
symmetrical, generalized light brown macules with a well demarcated border ranging
from 3 mm to 5 mm, smooth Vermillion border. Pt has a raised papule on the right
side od lower lip that is skin color and well demarcated ranging from 2 mm by 2 mm.
• Lymph nodes: not palpable or tender.
• Glands: not tender.
• TMJ: Popping and clicking on right side only. Smooth motions on left side. Pt reports
no pain or tenderness. Adequate range of motion.
CLINICAL FINDINGS: IO
EXAMINATION
• Intraoral Exam
• Labial/Buccal mucosa: bilateral linea alba, bilateral Fordyce granules, no lesions, moist, intact.
• Palate: palatal torus, raphae and rugae intact.
• Oropharynx: Palatal tonsils not present, throat is red, patient reports it is not sore.
• Tongue: smooth, symmetrical, moist
• Salivary Flow: Adequate flow, milkable ducts.
• Frenum attachments: between #8 and #9, between #24 and #25
• Lymph nodes: not swollen or tender
• Glands: not tender, adequate flow
• Deviation on 10/23/23: Pt had a lesion on left buccal mucosa from biting cheek. It is a raised red/pink papule with
a well demarcated border ranging from 1 mm by 2 mm.
RADIOGRAPHIC FINDINGS - VBWX
VBWX FINDINGS
• No caries observed.
• Monitoring #1 and #16 due to an impacted wisdom tooth.
• Pt has an amalgam overhang on #2, #3, #18, and #30.
• Pt has radiographic bone loss extending to the middle third of the root. The
bone loss is vertical and horizontal.
RADIOGRAPHIC FINDINGS –
PANORAMIC
CLINICAL FINDINGS-
MALOCCLUSION CLASSIFICATION
• Angles Classification of Occlusion: Class I molar and canine relation
• Open bite: anterior 2mm
• Overjet: N/A due to open bite
• Midline: deviated 2 mm to the right
• Crossbite: none
• Tooth Alignment: torsiversion on #23, #26, and #27
• Open contacts: none
• Parafunctional habits: none
• CAMBRA: high
CLINICAL
FINDINGS:
DENTAL CHART
#1 – unerupted
#2 – MODB amalgam
#3 – crown
#4 – DO composite #15 – MODB amalgam
#5 – O amalgam #16 – unerupted
#6 – M composite #17 – extracted
#7 – veneer with endodontic Watches:
#18 – crown
therapy #9 – ML discoloration on restoration
#19 – crown
#8 – ML composite #10 – ML discoloration on restoration
#20 – DO amalgam
#9 – DL composite #15- OL discoloration
#29 – DO composite
#10 – ML composite #30 – crown
#12 – O amalgam #31 – crown with endodontic therapy
#13 – missing #32- extracted
#14 – crown
CLINICAL FINDINGS: HARD TISSUE
ASSESSMENT
• Caries Risk Assessment (CAMBRA)
• High
• Pt consumes sugary foods/drinks throughout the day causing prolonged exposure
to tooth structure.
• Medications that reduce salivary flow (Trazodone)
• Unusual tooth morphology that compromises oral hygiene
• Interproximal restorations
• Open contacts
- Nicotine Dependance is nonapplicable to this patient.
GINGIVAL ASSESSMENT
• Periodontal Maintenance – Baseline Data • Periodontal Maintenance 3 month Re-care
• Pale pink • Tissues were the same as the first visit
• Flat to tooth • Localized edema and erythematous tissue on
• Tapered #18, #19, #30, #31
• Pyramidal • NSPT Re-eval
• Stippled • Rolled gingival margin on all anterior teeth
• Resilient
• Localized edema on #18, #19, #30, #31
PERIODONTAL EXAMINATION: AT
NSPT DIAGNOSIS
DENTAL HYGIENE DIAGNOSIS
• At the initial visit with this patient, she expressed that she is aware she has periodontal
disease, and she alternates every 3 months with her periodontist and dental hygienist.
We took VBWX and noticed she does have significant bone loss. She had some deep
pockets and suppuration. However, she did not have over 30% BOP. We classified her
as a calculus III, perio IV with no stage and grade. Therefore, we chose to complete a
periodontal maintenance and see her again in three months.
• Three months later was her periodontal maintenance recare. At this appointment she
expressed that she had no been faithful with her oral hygiene at home as well as she
should have been. She had deeper pockets and excessive BOP. We classified her as a
calculus III, perio IV stage III grade B due to active disease. We decided to perform full
NSPT on the right side, and localized NSPT on #14, #15, #18, and #19.
TREATMENT PLAN
• Periodontal maintenance on reduced periodontium with no signs of infection.
• NSPT on Quads 1 and 4 with local anesthesia.
• Localized NSPT on Quads 2 (#14 and #15) and 3 (#18 and #19).
DENTAL HEALTH EDUCATION AND
OHI
• Oral Hygiene Education
• plaque accumulation at GM on the lingual aspect and interproximal
• Modified Bass
• String floss and floss pic
• Electric toothbrush
• Water pic
• OTC fluoride products
• Switched to modified stillman at re-care due to some localized inflammation around crowns
• Discussed bringing plaque score from 65% to 40%
IMPLEMENTATION – LA
DOCUMENTATION
• 10/24/23
• R PSA • R ASA
• 10:25 am
• 9:39 am
• Administered by Mackenzie
• Administered by Mackenzie Whitley Whitley
• 2% Lidocaine w/ epi 1:100,000 • 2% Lidocaine w/ epi 1:100,000
• 20% Benzocaine topical, mint
• 20% Benzocaine topical, mint flavor flavor
• 27 mg administered (3/4 cartridge) • 23 mg administered (2/3
cartridge)
• 25 gauge short needle • 25 gauge long needle
• Height of MB fold over 2nd molar DB • Height of MB fold over 1st
root. premolar
• Pt tolerated procedure well, no
• Pt tolerated procedure well, no adverse adverse reactions observed.
reactions observed.
IMPLEMENTATION – LA
DOCUMENTATION
• 11/15/23
• R IANB
• R Buccal
• Administered by Mackenzie Whitley • Administered by Mackenzie Whitley
• 9:28 am • 9:28 am
• Lidocaine w/ epi 1:100,000 • Lidocaine w/ epi 1:100,000
• 20% Benzocaine topical, mint flavor
• 20% Benzocaine topical, mint flavor • 25 guage long needle
• 25-gauge long needle • 9 mg administered
• 27 mg administered • Distal and buccal to most terminal tooth in
• ¾ distance from notch to deepest part of arch.
raphae, barrel over 2nd premolar on opposite • Pt tolerated well and experienced no adverse
side. reactions.
• Pt tolerated well and experienced no
adverse reactions.
IMPLEMENTATION – ARESTIN
• Surfaces - #2 ML, #3 DL, #4 ML, #5 ML
• Administered by Mackenzie Whitley
• Post op instructions given to patient to not brush for 12 hours, not to floss for 10 days,
and to avoid crunchy/sticky foods around areas listed above.
• Pt tolerated procedure well and experienced no adverse reactions.
RESULTS OF TREATMENT: RE-
EVALUATION
Pt had decreased pocket depths and less than
30% BOP at the re-care visit. The patient had
less plaque biofilm and calculus accumulation
as well. The patient was classified a calculus
II, perio III at this visit. There were still a few
4- and 5-mm pockets but it had improved from
before the NSPT.
RE-CARE PLAN
• This patient has now returned to health. Therefore, this patient is a periodontal
maintenance on a reduced periodontium and will be on a 3-month re-care
schedule.
