Periodontal+Case+7+-+Atherothrombosis

Periodontal Case #7 - Atherothrombosis

John Doe is a 60 year old married Caucasian male who is retired. His physician is Dr. Jones. On his dental information he disclosed that he experiences dry mouth and bleeding gums when he brushes. His chief complaint is that he has a tooth with a hole in it and just started bothering him 2 weeks ago. He is here today because he would like his teeth cleaned. His last dental exam, FMX, and cleaning were in 2006.
 * Patient Profile:**


 * __Our patient states:__**
 * He’s had a history of angina, arteriosclerosis, and coronary occlusion, and damaged heart valves since 2003.
 * He has difficulty breathing (especially lying down)
 * He also presents with high cholesterol and high blood pressure since 2008.
 * He is nearsighted and wears reading glasses since 1992.
 * He currently smokes a pack of cigarettes a day for the past 35 years and drinks alcoholic beverages socially.
 * He experienced some numbness and tingling in his arms 2 years ago.
 * He had his childhood vaccinations as an infant and a flu vaccine in Oct. of this year.
 * His father had heart disease and type 1 diabetes. He is no longer alive due to the heart disease
 * He is allergic to sulfa drugs and develops a rash.
 * For extra information patient reports: Often feeling tired and has lack of concentration.



 "Inflammation is a key factor in the development of atherosclerois. As LDL cholestorol accumulates in the arterial wall, it undergoes chemical changes and signals to endothelial cells to latch onto white blood cells circulating in the blood. These immune cells pernetrate and trigger an inflammatory response, driving LDL's to become "foam cells" and form a fatty streak, the earliest stage of atherosclorotic plaque. The plaque continues to grow and grows a fibrous cap. Substances released from fibrous cell are eventually dislodged allowing it to rupture, causing a blood clot which can block blood flow and trigger a heart attack."




 * Medications: **

1) Plavix 75mg Taken for: Anherothrombosis.... prevents platelet aggregation Dental Implications: Block platelet aggregation and prolongs bleeding time. Under the authority of the patients physician, the patient should discontinue the use of the drug 5-10 days prior to their appointment. Dental Contraindications: Hypersensivity to Plavix or any drug formulation.

2) Lisinopril/HCTZ 30/80 Taken for: High blood pressure Dental Implications: none Dental Contraindications: Monitor vitals. Can cause orthostatic hypotension

3) Nitroglycerin sub Taken for: Angina Dental Implications: xerostomia Dental Contraindications: hypersensitivity to any drug formaulation

4) Aspirin 81mg Taken for: mild blood thinner. Taken in conjunction with Plavix to help treat Atherosclerosis Dental implications: prolonged bleeding time Dental Contraindications: Hypersensitivity to aspirin or any drug formulation including NSAID

5) Lipitor 20mg: Taken for: High cholestorol. Helps increase HDL and lower LDL Dental implications:none Dental Contraindications: Hypersensitivity to Lipitor or any drug components of the following. Secondary cause of hyperlipidemia should be ruled out before treatment and Liver function should be monitored.

6)Amoxicillan 2000mg Taken for: Prophylactic medication prior to dental treatment Dental implications: Prolonged used of penicillins can lead to development of oral candidiasis. Dental Contraindications: Hypersensitivity to Amox. or penicillin.

Note* Individuals with Atherosclerosis often experience tachycardia and difficulty breathing
 * __Vitals __****:** BP:142/89, P: 101, R:13

__**Assessments:**__ __Extra oral:__ No atypical findingsIntra oral: __Intra Oral:__ Has a 3x5 ulceration superior to #10 that is fibrous and inflammed. Differential: Irritation fibroma or localized gingival enlargement.TMD: NoneGIngival Description: __Attached__: generalized erythematous, edematous, glossy, and some loss of stippling in the anterior region. __Free:__ generalized pink with localized erythematous in the areas between 8 & 9, 10 & 11, 12 & 13, 21 & 20, 22 & 23, and 24 & 25. Fills embrasures bulbous and shiny.Maximum opening: 47mm.Facial Profile: mesognathic Angles __Classification:__ class I bilaterally with end to end bite on 10 & 23. #11 is lingually inclined.MBI: 95%BOP: 90% with generalized probing depths of 3 and 4's w/localized 5'sRecession: He has 1mm on 22 & 27.Furcations: NoneMobility: + on #'s 8 & 9, 24,25,26, and class I on #'s 6,7,10,11,12 Mucgingival Defects: None ADA III AAP: generalized moderate chronic periodontitis due to plaque and calculus and modified by smoking MVC Calculus Code: medium

__ Oral Hygiene __ : uncontrolled
====__ Influencing Cultural and Social Factors __ : Pt. is elderly and retired and living on a fixed income so he may not have the financial ability to keep up his oral hygiene regimen and pt’s dexterity may be effected due to his age. ====

Oral Health Education/Strategies:

 * 1) ====__ Oral Health Belief Model __ : Pt. is in the pre-contemplation stage of the transtheoretical model. He seems to have little to no interest in modifying his oral hygiene behaviors. ====
 * 2) ====__ Recommended OHI __ : Introduce the Bass brushing technique, rubber tip, applicator, C shaped flossing, alcohol free mouth rinse, and smoking cessation ====

__ Rationale __ : Pt. has uncontrolled perio, caries, and oral hygiene
__**Treatment Plan:**__


 * Med. consult sent out to cardiologist and physician prior to treatment


 * Appt. 1- FMX, x-ray check, gather assessments, smoking cessation


 * Appt. 2- DDS exam, second check-in, PI/OHI ( bass brushing technique w/ soft toothbrush). Smoking cessation.


 * Appt 3- OHI (evaluate bass brushing technique and evaluate any resolution of tooth sensitivity, and introduce alcohol free mouthrinse). Smoking cessation. Scale URS w/ carbocaine 3% w/o vasopressor (injection: PSA & GP). Subgingival irrigation with chlorohexadine, and flouride varnish.


 * Appt. 4- OHI (reinforce bass brushing and introduce rubbertip applicator). Smoking cessation. Scale UAS w/carbocaine 3% w/o vasopressor (injection: ASA & NP). Subgingival irrigation w/ chlorohexadine, and flouride varnish.


 * Appt 5-OHI ( reinforce rubbertip applicator and introduce C-shaped flossing).Smoking cessation. ULS w/carbocaine 3% w/o vasopressor (injections: PSA & GP). Subgingival irrigation with chlorohexadine, and flouride varnish.
 * Appt. 6- (reinforce all homecare techniques taught). Smoking cessation. Scale LLS w/carbocaine 3% w/o vasopressor (injections: IA/B). Subgingival irrigation w/ chlorohexadine, and flouride varnish.


 * Appt 7- OHI ( continue to reinforce homecare) Smoking cessation. Scale LAS w/ carbocaine 3% w/o vasopressor (injections: IA). Subgingival irrigation with chlorohexadine, and flouride varnish.


 * Appt 8- OHI (continue to reinforce home-care techniques and make any adjustments if necessary). Smoking cessation. Scale LRS w/ carbocaine 3% w/o vasopressor (injections IA/B). Subgingival irrigation with chlorohexadine, and flouride varnish.


 * Appt. 9- 4-6 week re-evaluation.


 * Appt. 10- 3 month re-care