A 53 year old patient attends for a check-up. They haven’t been to a dental clinic for about 4 years due to Covid. They smoke approximately 15 cigarettes a day and drink 2-3 beers each week. They
take aspirin each day as well as Lipitor. The patient works night shift at a local mine Friday nights to Tuesday nights. They drink 2-3 coffees a day with sugar, and also consumes energy drinks on
occasion. They usually brush their teeth at night time before they go to work, but they don’t generally clean interproximal. They use a medium toothbrush with a Colgate toothpaste.
E/O: crepitus LHS TMJ; nil pain associated.
I/O: bilateral linea alba, saliva appears frothy
Odontogram: moderate attrition entire dentition; incipient caries 25D, 26M; caries 15D, 16M, 36O,
46MO
Perio Chart: see below
Risk factors: smoking, alcohol, energy drinks, sugar and coffee, OH (brushing 1 per day with medium toothbrush, irregular attendance), aspirin (blood thinner, past MHx, frosty saliva (dehydrated tissue and caries risk), attrition (bruxism).
Clinical Notes
C/C: patient has attending today for a check up
MHx: Taking aspirin (blood thin) and Lipitor every day
DHx: last check up was 4 years ago
OH: brushes with medium toothbrush one a day at night, using Colgate toothpaste, no clean interproximal
SHx: works night shift from Friday night to Tuesday night.
Diet: smoke 15 cigarettes a day, drink 2-3 beers each week. Drink 2-3 coffees a day with sugar, consumes energy drinks on occasionally.
Consent:
E/O (Extra Oral): crepitus LHS TMJ; nil pain associated.
I/O (Intra Oral): bilateral linea alba, saliva appears frothy
PSR (Periodontal Screening and recording): 4 2 3/ 3 2 3
Odontogram/Hard Tissues: moderate attrition entire dentition;
caries 15D, 16M, 36O, 46MO
Demineralization: 25D, 26M
Additional diagnostic tests/investigations required (if any):
BWs for caries and bone loss, OPG,
Saliva teststing, plaque index, PRS
Risk assessments:
Periodontitis stage III, grade C: smoke, bone loss furcation, pocket <=5
High risk of caries
Discussion with patient:
– Flossing daily and go deep subgingival both sides
– Advise to use Colgate Savacol to anti-inflamatory
– Advise to bring the children to have a dental check-up.
– Advise to have routine dental check up every 6 months
Diagnosis: mild generalised plaque induced gingivitis on sextant 2 and sextant 5, localised periodontitis on sextant 1
Consent gained to proceed with debridement ater discussion of risks not limited to post op sensitivity, bleeding for a few days.
Treatment Plan: Quadrant scaling if heavy deposit with LA consent or half mouth, OHI, fluoride, smoking cessation (with consent), brushing with soft, some interproximal, high F, diet.
N/V: Debridement sextant 1