Clinical Notes:
Reason for Attendance: Finish clean
Medical History: Updated – see Medical History Questionnaire
Soft Tissue: No Abnormality Diagnosed
DH: Follow up the previous apps. Finish debridement sextant 2 and sextant 5
Examination and clean : Consent gained to proceed.
E/O:
Lymph nodes: NAD
Thyroid glands: NAD
Salivary glands: NAD
Sinuses: NAD
TMJ: NAD
Muscle of mastication: NAD
Facial swelling: NAD
Lips: NAD
Speech: good
I/O:
Tonsils: enlarged
Palate: NAD
FOM: NAD
Saliva quality: low quality
Buccal mucosa: enlarge parotid papilla
S/T:
Gingiva: puffy, BOP
Plaque: yes
Calculus: yes
PSR: 430 030
Diagnosis: mild generalised plaque induced gingivitis
H/T:
Restorative: early caries on 24M
Discussion:
Educate the patient the value of maintaining good dental health. The patient is aware that periodontal disease is inherited. Due to periodontitis, his mother lost all of her teeth. He was raised in a developing country and never had regular dental examinations. He only went to the dentist when he was having issues. Inform him that periodontal disease won’t show symptoms until it’s too late and treatment options are limited. The outcome indicated that he has extensive tooth loss as a result of periodontitis. In the Philippines, he had prosthetic operations on the bridges from 34 to 38 and 43 to 47. The bridge is very extended, and his lack of cleanliness caused caries on teeth 34, 43, and 47. He lost both of the bridges as a consequence. It influences the way he bites and eats. Remind him that the first step should be prevention. As a result, he has abilities to help his three children get educated.
Demonstrate the brushing technique and floss between interproximal. Advice him to use floss rather than the toothpicks.
Advice to see the student dentist for the denture option to improve eating function.
Based on the diagnosis at the last session, tooth 16 had a poor prognosis and required root canal therapy (RCT). However, bone loss and deep pockets on the palatal and distal surfaces suggest that the tooth may not survive long after RCT. Pt noticed tender when eating but assumed that the treatment had completed. Patient consider any options that can improve his biting and also the cost of it.
Book patient back with student for further consultation about the denture and replacing teeth option. Schedule a follow-up appointment to debridement on sextant 1,2 and 5. The patient now understands how crucial it is to maintain healthy teeth and gums.
Treatment today:
– Debridement sextant 2 and sextant 5 with hand scaler and full mouth prophy
– OHI – brushing and pikster use demo given
– Give prognosis on 16. Either need RCT or EXO in the future but the PD on 16M was 6mm.
Radiographs: not indicated
TPLAN:
- Exo 34 root stump with CSU dentist student
- Access the existing denture either tooth addition or add clasp on 33 to stablise when eating as pt reply on RHS due to no molar on the LHS.
- Follow up tooth 16.
6 month recall
Next Appointment: EXO 34