Critical Thinking Case History – Perio
Patient: Multiple Martha is a 60-year-old white female who presented for a recall appointment
Chief Complaint: “I want cleaner whiter teeth”
Medical History:
Heart Murmur with
Regurgitation Type II diabetes
Arthritis – right hand with limited dexterity
Medications: Glucophage Aspirin 325mg BID Garlic
Habits:
Smokes 1 pack of cigarettes/day
Health Behaviors:
Brushes 1x/day with manual TB (misses the gingival margins of the facial and lingual of all molars No rinsing or flossing
EIOE:
White 2mm/2mm raised area on left lateral border of the tongue
Periodontal Assessment: Generalized mild/localized Chronic Periodontal Disease
Gingival Description: Generalized moderate marginal and papillary erythema and edema with localized cyanotic tissue on the lingual margins of the #23 - #26.
Probe readings – generalized 3-4 mm with localized 5-6 mm in the molar areas, 8mm MF # 7, Generalized 1-2 mm CAL, Bleeding Index: 50%
Accretions: Generalized moderate supra and subgingival calculus
Plaque free Index: 10%
Radiology: Generalized horizontal bone loss
Hard Tissue: Several class I and class II amalgams, amalgam overhangs are present
Critical Thinking Case History – Caries
Patient: Carrie Case is a 40 year old white female who presented for a recall appointment
Chief Complaint: “I want cleaner whiter teeth”
Medical History:
Seasonal Allergies
Depression
Medications:
Flonase
Paxil
Habits:
Sips on Coke a cola throughout the day
Health Behaviors:
Brushes 1x/day with manual TB (misses the gingival margins of the facial and linguals of all molars) No rinsing or flossing
EIOE: wnl
Periodontal Assessment: Generalized gingivitis
Gingival Description: Generalized marginal gingivitis and erythema. Marginal gingival rounded on #14.
Probe readings: generalized 3-4mm readings with localized CAL readings of 1mm on #14 & #18.
Bleeding Index: 10%
Accretions: Generalized light supra and subgingival calculus
Plaque free Index: 20%
Radiology: Patient presents with multiple interproximal carious lesions
Hard Tissue: Several class I and class II amalgams
Class V caries facial #’s 18, 20 &14
