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
