Periodontal Case #3 - HIV

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Patient Profile:

Our pt. is Salvador Estrada, he is a 44 yr. old single Hispanic male. His physician is Dr. Jacobs. His chief complaint is painful gums and is also here to have his teeth cleaned. He is currently experiencing bleeding gums since 2005. He also has sensitivity to cold, hot, sweet, and pressure throughout his mouth. Date of last dental exam, fmx, and deep cleaning where done in 2001. Pt. has history of blisters and sore on the lips and mouth since 1994 and swelling in the mouth. Pt. has loose teeth due to severe periodontitis since 2004. Pt. was diagnoses with stage I hypertension and is controlled with meds. Pt. has current history of tuberculosis and persistent cough since 1992. Pt. has pneumonia and bronchitis in 1992. Has visual impairment and wears reading glasses since 2009. Has past history of tobacco use and quit in 1992. He has a past history of drug use. Pt. used heroin from 1987 to 1989. He also has a past history of fainting spells. His last episode was in 1993 from a medication he was taking at the time. He has recent and re-current headaches since 2000. Pt. has persistent diarrhea and nausea due to medications. Pt. has a past history of urinary infection; last infection was Jan. 2011 and was treated with antibiotics. Pt. has the HSV type I and II. Pt. has frequent cold sore due to HSV I; his last episode was 9/2011. Pt. was diagnosed with HIV in 1992. He was diagnosed with depression in 1995 and is treated with meds. He had his childhood and Hep. B vaccinations completed in 1995. He has a family history of tuberculosis both his mother and father had it. He has no known allergies. He was hospitalized in 1992 for bronchitis and pneumonia. He had and emergency room visit in 1999 for a fainting spell. He is currently taking Lisinopril for hypertension, Avacavir and Stavudine for HIV. Chlortramazole for Thrush, Vicodinforpain, Acyclovir for HSV I and II, and Prozac for depression.


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Medication

  • Abacavir 300mg BID: Taken for HIV. Dental implications: none. Dental Contraindications: mouth ulcerations

  • Stavudine 30mg BID: Taken for HIV. Dental implications: none. Dental Contraindications: none

  • Lisinopril 20mg: Taken for high blood pressure. Dental implications: none. Dental Contraindications: xerostomia, monitor blood pressure prior using local anesthetic with vasoconstrictors

  • Clortramazole 500mg daily: Taken for Thrush and other persistent fungal infections. Dental implications: none, Dental Contraindications: none

  • Vicodine 5/325 PRN: Taken for pain from recurrent shingles. Dental implications: for acute pain. Dental Contraindications: xerostomia

  • Acyclovir 200mg: Taken for cold sores. implications: none. Dental Contraindications: Dry cracked lips.

  • Prozac 20mg: Taken for depression. Dental implications: none. Dental Contraindications: xerostomia. Monitor patient vitals following LA.



Assessments:
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  • Vitals: BP: 130/87, P: 72, R: 18
  • Extra oral: minor rash inferior to right ear 4x5 multiple erythmaotous raised lesions. Patient reports rash started two weeks ago and is recurs approx. every two weeks. Generalized diastemas.
  • Intra oral: 5x3 white, round, ulceration with red halo with a 2x2 satellite lesion, very painful. Patient repots lesions started 4 days ago, maxillary tori, lingual varicosities, and removable non-painful white lesion located on the dorsal surface of the tongue.
  • TMD findings: none
  • Gingival Description:
  • Attached: Generalized Erythematous, Edematous, Glossy and Shiny with loss of stippling.
  • Free: Generalized erythematous, , and blunted (inter-dental papillae) Hemorrhagic,localized rolling on the maxillary and mandibular posterior teeth, Bulbous #6-11 and #22-27, and shiny.
  • Marginal Bleeding: 64%
  • Periodontal Examination: Generalized 4-5 mm with localized 6 on the distal of # 2, 5, 14 and 15. localized 7mm on the mesial of #2 and #18, and #30 and localized 8mm on the mesial of #30
  • Recession: Generalized 1-2mm on the facial incisors both buccal and lingual. Localized 3-4mm on the buccal of #7 and 4-5 mm recession on the facials of #22 and #27.
  • Furcation: Class II furcation on the buccal of #31, #30, #2 and #5.
  • Mobility: Class II mobility on teeth 7-11 and 22-27.
  • Fremitus: Class I on # 7-11
  • Mucoginvial Problems: #7, 3, 11, 22 and 27
  • Angles Classification: Class I bilaterally/end to end bite on #6 and 27
  • Facial Profile: Mesognathic
  • Salivary flow: Inadequate
  • ADA/AAP: Generalized ADA III with localized ADA IV. AAP: Generalized severe chronic periodontitis due to plaque and calculus modified by HIV and medications.
  • MVC calculus code: Medium/Heavy
  • Prognosis: Poor
  • PI: 79%
  • Missing teeth: 1, 16, 17, 32 due to extraction of wisdom teeth.
  • Existing restorations: #2 MOD amal, #3 OL amal, #19 OB, #30 MOD
  • Possible Areas of Decay: 3 O , 7 Facial (frank decay), 8 Facial (frank decay), 9 Facial,
  • Radiographic Possible Areas of Decay: 3 M, 27 D, 28 M
  • Atypical Findings: frank decay on the facial of 7 and 8
  • Radiolucencies on Radiographs: apex of 7 and 8 (periapical abcess)
  • Intrinsic/Extrinsic Resorption: 7 and 8 (extrinsic) (due to periapical abscess)
  • Root Resorption: 7 and 8 (due to periapical abscess)
  • Dilacerated Roots: none
  • Other Atypical Anatomy Findings: none

Critical Thinking:
Chief Complaint: Pt. states he is “here because he has painful bleeding gums and to get his teeth cleaned.
Medical History/Systemic Health: HIV
Oral Risk Factors: xerostomia, rampant root decay, increased risk of perio, oral candidiasis, Kaposi’s Sarcoma, oral ulcerations.
Dental Health Diagnosis: Perio: uncontrolled, Caries: uncontrolled, Oral Hygiene: uncontrolled
Influencing Cultural and Social Factors: Pt. works full time and may not have the time to implement proper hygiene and sometimes lacks energy due to immunosupression.
Dental Hygiene Care Plan:
Oral Health Education/Strategies:
1. Oral Health Belief Model: Contemplation stage of the transtheoretical model: Pt. seems
motivated to learn proper oral hygiene techniques.
2. Recommended OHI: Introduce Bass brushing technique and “C” shaped flossing.
Recommend interproximal brush and rinsing with an alcohol free mouthwash and recommend
Sensodyne.
Implementation/Hygiene Services:
1. Instrument Selection: Piezo, sickles, graceys, files, nevis
2. Anesthesia/Rational: for patient comfort
Reevaluations: Resolution of ulceration and satellite lesion and resolution of white, removable lesion on dorsal surface of the tongue.
Anticipated Treatment Outcomes: maintain pocket depths and decrease BOP’s by 20%
Referrals: general practitioner, endo, and perio
Recall Interval: 3 month re-care
Rationale: Pt. has uncontrolled perio, caries, and oral hygiene

Treatment Plan:
Appt. 1- FMX, xray check, gather assessments
Appt. 2- DDS exam, second check-in, PI/OHI ( bass brushing technique w/ soft toothbrush and Sensodyn dentrifice)
Appt 3- OHI (evaluate bass brushing technique and evaluate any resolution of tooth sensitivity, and introduce alcohol free mouthrinse) scale URS w/ anesthesia ( injection: PSA & GP). Subgingival irrigation with chlorohexadine, and flouride varnish.
Appt. 4- OHI (reinforce bass brushing and introduce rubbertip applicator). Scale UAS w/ anesthesia (injection: ASA & NP). Subgingival irrigation w/ chlorohexadine, and flouride varnish.
Appt 5-OHI ( reinforce rubbertip applicator and introduce C-shaped flossing). ULS w/ anesthesia (injections: PSA & GP). Subgingival irrigation with chlorohexadine, and flouride varnish.
Appt. 6- ( reinforce all homecare techniques taught). Scale LLS w/ anesthesia (injections: IA/B). Subgingival irrigation w/ chlorohexadine, and flouride varnish.
Appt 7- OHI ( recommend salivary substitute) Scale LAS w/ anesthesia (injections: IA). Subgingival irrigation with chlorohexadine, and flouride varnish.
Appt 8- OHI (continue to reinforce home-care techniques and make any adjustments if necessary). Scale LRS w/ anesthesia (injections IA/B). Subgingival irrigation with chlorohexadine, and flouride varnish.
Appt. 9- 4-6 week re-evaluation.