Periodontal+Case+1+-+Hyperplasia

Case #1 - 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__
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 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. 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. 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 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.
 * Dilantin: dose 15mg/day, period of time taken 1995 to current
 * Metformin: dose 1,000mg 2x daily
 * Zocor(simvastatin): 40mg one time a day
 * Lasix(furosemide) : 20mg one time a day
 * Enalapril: 20mg one time a day

__**<span style="font-family: Arial,Helvetica,sans-serif;">Assessments: **__ <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">Extra oral findings: None <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">Intra oral findings: Bilateral linea alba and generlized gingival hyperplasia. <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">TMD Findings: None <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">Salivary Flow: adequate <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">Maximum Opening: 52 mm

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">Free Gingiva: Erythmatous, fibrotic, bulbous and blunted interdental papilla, clefting on facial of #25 and #27 and glossy. <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">Attached Gingiva: Fibrosis, fibrotic, and glossy. Angels class: Class I normal occlusion. Facial profile: Mesognathic. MBI 0%. BOP 2%. <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">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. <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">Furcations: none. Mobility: (+) #7-9 and #24-26. Fremitus: (+) 7-10. Mucogingival defects: none. PI:42 %

__**<span style="font-family: Arial,Helvetica,sans-serif;">Radiographic evaluation: **__
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: <span style="font-family: "Arial","sans-serif";">Generalized slight chronic periodontitis due to plaque and calculus and modified systemic illness. <span style="font-family: "Arial","sans-serif";">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: Gingivectomy Recall interval: 3 mo RC Rational: 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: ** **__<span style="color: black; font-family: "Arial","sans-serif";">Appointment 1: __**
<span style="color: black; font-family: "Arial","sans-serif";">S: Patient states he “is here <span style="font-family: "Arial","sans-serif";">for dental hygiene care and wants to discuss gingivectomy.” <span style="font-family: "Arial","sans-serif";">O: RMH, B/P: 126/84, P: 74, R: 16. E & I exam: No findings. <span style="font-family: "Arial","sans-serif";">A: ASA II <span style="font-family: "Arial","sans-serif";">P: X-ray check, completed FMX (18 films), completed gathering assessments, and tobacco cessation. <span style="font-family: "Arial","sans-serif";">N.V: DDS exam and 2nd check-in. <span style="font-family: "Arial","sans-serif";">--AdamsBaezaBobovaCadena #2012- <span style="color: black; font-family: "Arial","sans-serif";">S: Patient states he “is here <span style="font-family: "Arial","sans-serif";">for dental hygiene care and wants to discuss gingivectomy.” <span style="font-family: "Arial","sans-serif";">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 %. <span style="font-family: "Arial","sans-serif";">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. <span style="font-family: "Arial","sans-serif";">P: DDS exam, 2nd check-in, PI, OHI, and tobacco cessation. <span style="font-family: "Arial","sans-serif";">N.V: Scale LRQ and fluoride varnish.
 * __<span style="color: black; font-family: "Arial","sans-serif";">Appointment 2: __**

<span style="font-family: "Arial","sans-serif";">--AdamsBaezaBobovaCadena #2012-

<span style="color: black; font-family: "Arial","sans-serif";">S: Patient states he “is here <span style="font-family: "Arial","sans-serif";">for dental hygiene care and wants to discuss gingivectomy.” <span style="font-family: "Arial","sans-serif";">O: RMH-no changes, B/P: 124/86, P: 72, R: 17. E & I exam: no findings. <span style="font-family: "Arial","sans-serif";">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. <span style="font-family: "Arial","sans-serif";">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. <span style="font-family: "Arial","sans-serif"; font-size: 15px;">N.V: Scale URQ and fluoride varnish.
 * __<span style="color: black; font-family: "Arial","sans-serif";">Appointment 3: __**

<span style="font-family: "Arial","sans-serif";">--AdamsBaezaBobovaCadena #2012-

<span style="color: black; font-family: "Arial","sans-serif";">S: Patient states he “is here <span style="font-family: "Arial","sans-serif";">for dental hygiene care and wants to discuss gingivectomy.” <span style="font-family: "Arial","sans-serif";">O: RMH-no changes, B/P: 122/84, P: 72, R: 17. E & I exam: no findings. <span style="font-family: "Arial","sans-serif";">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. <span style="font-family: "Arial","sans-serif";">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. <span style="font-family: "Arial","sans-serif";">N.V: Scale LLQ and fluoride varnish.
 * __<span style="color: black; font-family: "Arial","sans-serif";">Appointment 4: __**

<span style="font-family: "Arial","sans-serif";">--AdamsBaezaBobovaCadena #2012-

<span style="color: black; font-family: "Arial","sans-serif";">S: Patient states he “is here <span style="font-family: "Arial","sans-serif";">for dental hygiene care and wants to discuss gingivectomy.” <span style="font-family: "Arial","sans-serif";">O: RMH-no changes, B/P: 126/84, P: 78, R: 18. E & I exam: no findings. <span style="font-family: "Arial","sans-serif";">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. <span style="font-family: "Arial","sans-serif";">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. <span style="font-family: "Arial","sans-serif";">N.V: Scale ULQ and fluoride varnish.
 * __<span style="color: black; font-family: "Arial","sans-serif";">Appointment 5: __**

<span style="font-family: "Arial","sans-serif";">--AdamsBaezaBobovaCadena #2012-

<span style="color: black; font-family: "Arial","sans-serif";">S: Patient states he “is here <span style="font-family: "Arial","sans-serif";">for dental hygiene care and wants to discuss gingivectomy.” <span style="font-family: "Arial","sans-serif";">O: RMH-no changes, B/P: 124/84, P: 72, R: 17. E & I exam: no findings. <span style="font-family: "Arial","sans-serif";">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. <span style="font-family: "Arial","sans-serif";">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 <span style="font-family: "Arial","sans-serif";">N.V: 4-6 week evaluation.
 * __<span style="color: black; font-family: "Arial","sans-serif";">Appointment 6: __**

<span style="font-family: "Arial","sans-serif";">--AdamsBaezaBobovaCadena #2012-

__<span style="color: #333333; font-family: "Arial","sans-serif";">Reference __ <span style="color: #333333; font-family: "Arial","sans-serif";">Carranza, F., Klokkevold, P., Newman, M., & Takei, H. (2006). //Carranza's clinical periodontology//. (10 ed., pp. 918-925). St. Louis, MO: Saunders Elsevier.--