Professional Documents
Culture Documents
Assessment Findings
85. Pt. drinks alcoholic beverages (1x a week)------------------- Hepatic damage, increase risk of systemic disease, cardiovascular
disease, digestive complications, stained teeth
88. Last dental visit was 2012 w BWX (cleaning) -------------- Caries, gingivitis, periodontitis, and oral cancer
92. Pt. gums bleed when brushing/flossing------------------ Increased risk of periodontitis, caries and opportunistic infections
93. Pt. teeth feel sensitive to cold and pressure--------------- Demineralization, possible incipient lesions
94. Pt. Clenches teeth when upset --------------------------- TMJ issues, attrition, abfraction, needs night guard
99. Pt. consumes sugary beverages less than 2x a week--- Demineralization, incipient lesions, cavities
Dental Examination At Risk For
pyknic body type ------------------------------------------------------- Increased risk of systemic diseases, high blood pressure,
cardiovascular diseases, and diabetes.
Prognathic ------------------------------------------------------------- Misalignment of occlusion could cause added stress to the
alveolar bone ultimately resulting in TMJ issues as time
progresses
Generalized ephelids etiology: developmental ----------------- Skin Cancer
Generalized scattered pustules on pt. face. Etiology: Bacteria-> Opportunistic Infection, scarring, possible Cancer
Single macule, normal color, normal border less than 1mm on
pt rt. Earlobe etiology: developmental----------------------------- Skin Cancer
Widened PDL space #24MD,#25D,#28D --------------------- Possible shift of neighboring teeth, occluding teeth, extraction
Attrition on maxillary/mandibular anterior teeth --------------- Demineralization, pain due to exposed dentin
Carious lesions #31DF---------------------------------------------- Root canal, loss of tooth
Periodontal Case Type: 2 Plaque Score: = 3.3% Bleeding Score: 9.5% (poor)
(3) Carious Lesions (3) Xerostomia/etiology: bacteria- poor oral hygiene, infrequent
dental visits/Risk for progression of bone
disease/edentulous/root caries
Planned Interventions
Expected Outcomes
Appt # Plan for Treatment Plan for Education, Counseling or Oral Hygiene Instruction
4 Medical/Dental Hx
Pre-Rinse Evaluate progress, make suggestions, and adjust/reeducate
Plaque/bleeding score X
Patient Education – Scaled LL