Case #1 - Hyperplasia

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Hyperplasia



Medical History:
Manuel Ortiz is a 35 year old male, single, ethnicity-Dominican, DOB: 8-11-75. He is a patient today for dental hygiene care also wants to talk to the dentist about gingivectomy. On his dental history the patient marked yes to bleeding gums when brushes his teeth since 1995, he clenches his teeth since July of 1996 and does not wear a bite appliance, and has enlargement of the gum tissue.
Last dental exam: December 2009.
Previous Dentist: Western Dental.
Last x-rays: December 2009.
Last cleaning: 2009– deep cleaning.
Cardiovascular Conditions: High Blood pressure-diagnosed in 200 and treated with medications.
Head/neck problems: Injury to head, 1995 hit in head with baseball-ER visit, 2001 head trauma from seizure- ER visit.
Social life- patient smokes a ½ pack of cigarettes a week and drinks beer socially on occasion, and no past use of crack, cocaine, or any other drug.
Neuromuscular System/CNS: Fainting spells or Loss of consciousness-due to seizures. Seizures: since 1995. Last episode in march 2011 and treated with medication. Muscle weakness: After patient has a seizure.
Hemo/Endo/Immune Disorders: Diabetes: Type 2 diagnosed in 2005. Controlled with medication and diet.
Patient reports he has never taken diet pills, childhood vaccinations were completed approximately in 1981, and Hepatitis B vaccination series completed in 2000, also patient received a Flu vaccine in October 2010.
Family History- Paternal father has type 2 diabetes; it’s controlled with medication and diet. Patient has no known allergic reaction.
Hospitalizations: ER visits-1995 from a seizure after being hit in the head with a baseball, 2001 from head trauma due to seizure. Pt. fell off of his chair at work and hit the right side of his forehead on his desk, and in 2009 the patient had surgery- overgrown gum tissue was removed.

Patient Medication


  • Dilantin: dose 15mg/day, period of time taken 1995 to current
Period of time taken: since 1995 to present
The medication is taken for: For management of seizures
Dental implication: gingival hyperplasia is a common problem, no effects on bleeding or local anesthetic.
Dental contraindications: Hypersensitivity to phenytoin, pregnancy

  • Metformin: dose 1,000mg 2x daily
Period of time taken: since 2005 to present
The medication is taken for: For management of type 2 diabetes mellitus
Dental implication: taste disorders; no effects on bleeding and local anesthetic precaution
Dental contraindications: Hypersensitivity to metformin, acute myocardial infarction, acute or chronic metabolic acidosis.

  • Zocor(simvastatin): 40mg one time a day
Period of time taken: since 2005 to present
The medication is taken for: For management of hyperlipidemia
Dental implication: no effects on dental treatment, bleeding, or local anesthetic precaution
Dental contraindications: Hypersensitivity to simvastatin, pregnancy, breast feeding, and unexplained elevation of serum transaminase.

  • Lasix(furosemide) : 20mg one time a day
Period of time taken: since 2005 to present
The medication is taken for: For treatment of hypertension
Dental implication: no effects on dental treatment, bleeding, or local anesthetic precaution
Dental contraindications: Hypersensitivity to furosemide or any components of the formulation, anuria
  • Enalapril: 20mg one time a day
Period of time taken: since 2005 to present
The medication is taken for: For treatment of hypertension
Dental implication: no effects on dental treatment, bleeding. Can cause abnormal taste and orthostatic hypotension
Dental contraindications: Hypersensitivity to medication, angioedema related to previous treatment with ACE inhibitors.

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Assessments:
Extra oral findings: None
Intra oral findings: Bilateral linea alba and generlized gingival hyperplasia.
TMD Findings: None
Salivary Flow: adequate
Maximum Opening: 52 mm

Free Gingiva: Erythmatous, fibrotic, bulbous and blunted interdental papilla, clefting on facial of #25 and #27 and glossy.Attached Gingiva: Fibrosis, fibrotic, and glossy.
Angels class: Class I normal occlusion.
Facial profile: Mesognathic.
MBI 0%.
BOP 2%.
Recession: Buccal/Facial #2-2mm, #3-2mm, #9-1mm, #21-26 1mm, #27-30 2mm, and #31 1mm. Lingual: #18 2mm, #19 1mm, #20 2mm, #21-28 1mm, #30 1mm, and #31 3mm. Furcations: none.
Mobility: (+) #7-9 and #24-26.
Fremitus: (+) 7-10.
Mucogingival defects: none.
PI:42 %


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Radiographic evaluation:

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Missing teeth- 1, 16, 17, 32 due to extraction.
Restorations- 2-O comp, 3-O comp, 12-DO ag, 13 MOD ag, 14-MO ag, 15-MO ag, 19-PFM, 20-DO ag, 29-DO ag, 30 PFM, 31-MO comp, no open margins noted or overhangs.
Possible areas of decay-20 upon oral observation possible re-current decay on the occlusal surface.
Radiolucency at apices of #20 and the distal root of #18 possible periapical cyst or periapical granuloma
Intrinsic absorption- none noted
Extrinsic absorption- none noted
Dilaceration of roots- slight dilaceration on the mesial & distal root of # 30
Root resoption- none noted
Atypical findings- none noted
General osseous: any radiolucent/radiopaque lesions or foreign objects- none noted
Quality of radiographs- vertical angulation on the UR pa of the molar and premolar rotate tube head mesial
Trabecular pattern- consistant throughout
Lamina dura- slightly fuzzy on the apicies of 18,19 and 31
Alveolar crest is generalized 3-4 mm from the CEJ.
Any horizontal or vertical bone loss- general horizontal bone loss w/ vertical bone loss on the mesial of #29
PDL space- widen PDL space on the mesial of # 20 and the apex of 18
Interadicular radiolucency- furcation-none noted
Calculus noted- none noted
ADA case type- II
AAP: Generalized slight chronic periodontitis due to plaque and calculus and modified systemic illness.
MVC calculus code: Medium.

Critical thinking form:

Chief complaint: Pt. wants gingivectomy, and teeth cleaned
Medical History/ Systemic Health: seziure medication, diabetes, and tobacco use.

Oral Risk Factors: Gingival Hyperplasia due to medication. Delayed wound healing due to diabetes, increase risk or periodontits due to diabetes and tobacco use,
and Xerostomia due to tobacco use.
Dental Health Diag.: Perio,Carries and Oral Hygiene = Uncontrolled
Influenceing cultural and social factors:Pt. suffers from seziures takes medication to control as a result pt. has ginival hyperplasia
Oral Health Belief model: Health Belief Model/stage 2, pt. believes "the condition is serious"
Recommended OHI: Soft bristle toothbrush using Bass method 2x a day, Floss 1x a day and demonstarte "C" shape flossing technique, and crest pro-health rinse 2x daily.
Instrument selection: Sickles, gracey, and universal.
Anesthesia /rational: yes, to maintain comfort due to the hyperplasia, pocket depths, and calculus code is Medium. Max=AMSA, PSA & GP Mand.= Gow gates
Reevaluations: gingival hyperplasia
Anticipated outcomes: reduce 5mm pocket depths to 4mm.Referals: Perio: GingivectomyRecall interval: 3 mo RCRational: Observe gingival hyperplasia and to maintain Oral hygiene.

Treatment Plan:

Appt. 1
18FMX
Assessments
Tobacco Cessation
Appt. 2
DDS exam
2nd check in
PI
OHI
Tobacco Cessation
Appt. 3
OHI
Scale LRQ w/LA 2% lidocain for pt's comfort. Perform Gow gates (1.8ml) injection.
Fl. varnish tx
Appt. 4
OHI
Scale URQ w/LA 2% lidocain for pt's comfort. Perform PSA (.9ml), AMSA (1.8), GP (.45ml) injections.
Fl. varnish tx
Appt. 5
OHI
Scale LLQ w/LA 2% lidocain for pt's comfort. Perform Gow gates (1.8ml) injection.
Fl. varnish tx.
Appt. 6
OHI
Scale ULQ w/LA 2% lidocain for pt's comfort. Perform PSA (.9ml), AMSA (1.8ml), GP (.45ml) injections.
Fl. varnish tx
Appt. 7
4-6 week re-eval

SOAP Notes: Appointment 1:

S: Patient states he “is here for dental hygiene care and wants to discuss gingivectomy.”
O: RMH, B/P: 126/84, P: 74, R: 16. E & I exam: No findings.
A: ASA II
P: X-ray check, completed FMX (18 films), completed gathering assessments, and tobacco cessation.
N.V: DDS exam and 2nd check-in.
------AdamsBaezaBobovaCadena #2012-----
Appointment 2:
S: Patient states he “is here for dental hygiene care and wants to discuss gingivectomy.”
O: RMH-no changes, B/P: 124/84, P: 78, R: 16. Extra oral findings: None, Intra oral findings: Bilateral linea alba and generalized gingival hyperplasia. TMD Findings: None. Salivary Flow: adequate. Maximum Opening: 52 mm. Free Gingiva: Erythmatous, fibrotic, bulbous and blunted interdental papilla, clefting on facial of #25 and #27 and glossy. Attached Gingiva: Fibrosis, fibrotic, and glossy. Angels class: Bilateral Class I normal occlusion. Facial profile: Mesognathic. MBI 0%. BOP 2%. Recession: Buccal/Facial #2-2mm, #3-2mm, #9-1mm, #21-26 1mm, #27-30 2mm, and #31 1mm. Lingual: #18 2mm, #19 1mm, #20 2mm, #21-28 1mm, #30 1mm, and #31 3mm.Furcations: none. Mobility: (+) #7-9 and #24-26. Fremitus: (+) 7-10. Mucogingival defects: none. PI: 42 %.
A: ASA II, ADA II, and AAP: Generalized slight chronic periodontitis due to plaque and calculus and modified by systemic illness. MVC calculus code: Medium.
P: DDS exam, 2nd check-in, PI, OHI, and tobacco cessation.
N.V: Scale LRQ and fluoride varnish.

------AdamsBaezaBobovaCadena #2012-----

Appointment 3:
S: Patient states he “is here for dental hygiene care and wants to discuss gingivectomy.”
O: RMH-no changes, B/P: 124/86, P: 72, R: 17. E & I exam: no findings.
A: ASA II, ADA II, and AAP: Generalized slight chronic periodontitis due to plaque and calculus and modified by systemic illness. MVC calculus code: Medium.
P: Scale LRQ with anesthesia, Administered gow gates on the patient’s right side, used 2% lidocaine with vasopressor at a total amount of 1.8 ml. Applied 5% sodium fluoride varnish. Advised patient to not eat or drink for 30 minutes, avoid gum, hard or sticky food or candy for 4 hours. Patient tolerated the procedure well and was dismissed from clinic in good condition.
N.V: Scale URQ and fluoride varnish.

------AdamsBaezaBobovaCadena #2012-----

Appointment 4:
S: Patient states he “is here for dental hygiene care and wants to discuss gingivectomy.”
O: RMH-no changes, B/P: 122/84, P: 72, R: 17. E & I exam: no findings.
A: ASA II, ADA II, and AAP: Generalized slight chronic periodontitis due to plaque and calculus and modified by systemic illness. MVC calculus code: Medium.
P: Scale URQ with anesthesia, Administered PSA, GP, and AMSA on the patient’s right side, used 2% lidocaine with vasopressor at a total amount of 3.15 ml. Applied 5% sodium fluoride varnish. Advised patient to not eat or drink for 30 minutes, avoid gum, hard or sticky food or candy for 4 hours. Patient tolerated the procedure well and was dismissed from clinic in good condition.
N.V: Scale LLQ and fluoride varnish.

------AdamsBaezaBobovaCadena #2012-----

Appointment 5:
S: Patient states he “is here for dental hygiene care and wants to discuss gingivectomy.”
O: RMH-no changes, B/P: 126/84, P: 78, R: 18. E & I exam: no findings.
A: ASA II, ADA II, and AAP: Generalized slight chronic periodontitis due to plaque and calculus and modified by systemic illness. MVC calculus code: Medium.
P: Scale LLQ with anesthesia, Administered gow gates on the patient’s left side, used 2% lidocaine with vasopressor at a total amount of 1.8 ml. Applied 5% sodium fluoride varnish. Advised patient to not eat or drink for 30 minutes, avoid gum, hard or sticky food or candy for 4 hours. Patient tolerated the procedure well and was dismissed from clinic in good condition.
N.V: Scale ULQ and fluoride varnish.

------AdamsBaezaBobovaCadena #2012-----

Appointment 6:
S: Patient states he “is here for dental hygiene care and wants to discuss gingivectomy.”
O: RMH-no changes, B/P: 124/84, P: 72, R: 17. E & I exam: no findings.
A: ASA II, ADA II, and AAP: Generalized slight chronic periodontitis due to plaque and calculus and modified by systemic illness. MVC calculus code: Medium.
P: Scale ULQ with anesthesia, Administered PSA, GP, and AMSA on the patient’s left side, used 2% lidocaine with vasopressor at a total amount of 3.15 ml. Applied 5% sodium fluoride varnish. Advised patient to not eat or drink for 30 minutes, avoid gum, hard or sticky food or candy for 4 hours. Patient tolerated the procedure well and was dismissed from clinic in good condition
N.V: 4-6 week evaluation.

------AdamsBaezaBobovaCadena #2012-----



Reference
Carranza, F., Klokkevold, P., Newman, M., & Takei, H. (2006). Carranza's clinical periodontology. (10 ed., pp. 918-925). St. Louis, MO: Saunders Elsevier.--