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The patient tolerated all of the treatment very well. He reported at his 30 day re-evaluation appointment that he could tell a big difference in the bleeding and soreness of his gums. He had began flossing daily and using mouthrinse daily as well as changing his diet some. He still has some pocketing but over all the condition of his mouth improved vastly.
-Patient filled out 7 day diet plan
-Showed pt. diet deficiencies
-Explained importance of the food groups.
-2 goals set:
1. Eat more fruit
2. Eat more dairy
Re-evaluation:
Pt. showed improvement in consumption
of fruit and dairy products
Generalized pink, pyramidal, firm, stippled with blunting in sextant 1 and 3
--Fine scaled all quads and removed light plaque and localized cliques of calculus.
--Very light bleeding
--Used .5 mL of chlorhexidine to sub-oral irrigate in localized areas of pocketing
--Nutrition improved: pt. had increased the intake of fruits and dairy in his diet
--Polished and flossed entire dentition
--Applied 5% NaF varnish
Generalized pink, knife-edged, firm, stippled
Generalized pink, adequate, firm, stippled
Generalized pink, pyramidal, firm, scalloped, and stippled with localized blunting in sextants 1 and 3
Angular bone loss #19,20,30 mesial
Generalized moderate horizontal bone loss
Loss of lamina dura #23,24,25
Generalized widening of the PDL
Retained root #32
Pulp stone #2, 15
Dilaceration #13,30
Generalized pink to red, slight rolling, soft, spongy, and smooth with localized ulcerating on the facial of #22, localized marginal redness on the lingual of #15, and localized knife edge firm, and stippled margins on the facial of sextant 2
Generalized subgingival calculus on posterior and anterior teeth.
Class I Amalgam: 3,14,15,18,20,30,31 Class II Amalgam: 2,5,12
Class I Composite: 19 Class V Amalgam: 31
3rd molars extracted in 1983
Generalized pink, adequate, firm, and stippled
linguoversion #26
distoversion #24
mesioversion #23
none
Contribute to the overall status and extent of the Mr. Perry O.'s condition
Medications the pt. is taking can cause candida and xerostomia.
generalized moderate subgingival calculus with localized supragingival calculus on mandibular lingual anteriors
Age: 50 yrs.
Race: Caucasian
Sex: M
Marital Status: Married
~ generalized freckles
~ wears glasses
~ 3x3 mm round, raised, brown mole on left cheek
~ generalized facial hair
- Controlled hypertension
- Mild asthma
- Very rare in between meals snacking
- smoked in younger years
- 2 alcoholic beverages per month
Vitals
BP: 118/78
Pulse: 66
Respiration: 16
bronchodilator
angiotensin receptor blocker (ARB)
leukotriene receptor antagonist
Last visit to dentist for cleaning was at least 25 years ago.
~ bilateral linea alba
~ slight palatal tori
~ skin tag on uvula
~ fordyce granules on labial commisures
* coated tongue
* 1x1 mm petechiae on lower right lip
Taylor Johnson
Northeast Texas Community College
Dental Hygiene Practicum
March 24, 2014