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I would like help writting a periodontal case report. Here is the information. The patient has moderate to server stage III perio.
i can insert photos of what I already have written
Rubric for Periodontal Paper
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Baltimore City Community College
Dental Hygiene
Rubric for Periodontal Papers
Please use the following rubric to construct your periodontal papers. This rubric is designed specifically for Periodontal Papers.
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Criteria |
10-8 |
7-5 |
4 – 2 |
1-0 |
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Patient Identification |
The paper utilizes all available data to clearly state the existing Periodontal condition. In addition, the paper identifies recommended treatment. |
The paper utilizes some of the data to identify the periodontal condition. The paper provides recommendations for treatment. |
The paper identifies the periodontal condition without the utilization of collected data. The paper provides a minimum amount of recommendations for treatment. |
The paper does not utilize the collected data to identify the existing periodontal condition and does not provide recommendation for treatment. |
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Symptoms and Rationale |
The paper clearly identifies all contributory factors of periodontal disease and identifies how each factor impacts the patient’s current periodontal condition. Moreover, the paper clearly identifies the prognosis and follow-up procedure including any necessary referrals for the patient. |
The paper identifies most contributory factors of periodontal disease and identifies how each factor impacts the patient’s current periodontal condition. The paper vaguely identifies the prognosis and follow-up procedure including any necessary referrals. |
The paper identifies a few contributory factors of periodontal disease, but does not associate these factors to the patient’s current periodontal condition. The paper lacks a prognosis, follow-up plan, and/or referrals. |
The paper does not identify contributory factors of periodontal disease and fails to mention the prognosis for the patient. |
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7-6 |
5-4 |
3 -2 |
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Scientific Accuracy |
The paper contains a minimum of 5 different references (within the past 5 years), 2 primary resources, and a bibliography/ reference list. |
The paper contains a minimum of 3-4 different references (within the past 5 years), 1-2 primary resources, and a bibliography/ reference list. |
The paper contains a minimum of 1-2 different references (within the past 5-8 years), 1 primary resources, and a bibliography/ reference list. |
The paper does not meet the minimum reference requirements, and does not contain a reference list. |
| 4 | 3 | 2 | 1 | ||||
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Proper Format |
The paper follows the APA format. The paper meets the required page length and each page is numbered. The paper is properly labeled with appropriate headings. The paper contains a cover page, 12pt font, doubled spaced, and uses Calibri print style . |
The paper meets the required page length and each page is numbered. The paper is properly labeled with appropriate headings. The paper contains a cover page, 12pt font, doubled spaced, and uses Calibri print style |
The paper does not meet the required page length and the pages are not numbered. The paper lacks the proper headings. The paper contains a cover page, 12pt font, doubled spaced, and uses Calibri print style |
The paper does not follow the APA format or meet the basic format requirements. |
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Timeliness |
The paper is turned in on or before the due date with the appropriate attached material |
The paper is turned a day after the due date. |
The paper is turned in two days after the due date. |
The paper is turned in 3 or more days after the due date. |
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Instructor Signature: |
Final Grade: |
PERIODONTAL CASE CONSULTATION
Directions
1. Prepare items listed in detail
2. Complete the items prior to the consultation
3. Make an appointment for your consultation prior to the deadline
4. Utilize textbooks and library references
5. Paper must be typewritten
Medical History
1. Outline the pertinent information
2. Indicate any precautions, medications, systemic complications with (*) in red
Dental History
1. Indicate past and present information
Oral Inspection
1. Outline pertinent information and describe abnormalities
2. Include intraoral photographs for gingival evaluation (intraoral photographs will also be taken after
treatment to be included with the periodontal paper for comparison)
Charting
1. List restorations and describe any abnormal conditions present such as overhangs or defective
margins
2. List caries, attrition, erosion and abrasion
3. List missing teeth
4. Include clinical charting form
5. Angle’s classification – malpositioned teeth
6. Periodontal probing and gingival index
7. Graphic charting
Model Evaluation
1. State arch form, determine symmetry, determine arch midline, and plane of occlusion
2. Evaluate Angle’s classification
3. Evaluate overbite
4. Evaluate overjet
5. Determine any crossbites
6. List individual teeth in malposition and list the type
7. List any drifting or tilting of the teeth
8. List any faceting or attrition of cusps
9. List any area of recession or cervical abrasion
10. Note any other visible abnormalities
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228
Radiographic Evaluation
1. List specific location of horizontal bone loss
2. List specific area of vertical bone loss
3. List areas where crestal bone is absent
4. List areas of thickened lamina dura
5. List any abnormal radiolucencies
6. List any sign of caries
7. List any sign of defective restorations
8. Lost areas of widened periodontal ligament
9. List specific areas of calculus evidence
10. List any impaction
11. List furcation involvement
Case Classification
Make a potential diagnosis of the case based on the American Academy of Periodontlogy Classification.
Diagnosis must be supported with evidence and rationate. (see appendix I for Periodontal Classification
System)
Recommendations
List a suggested treatment plan for the correction of all the patients’ periodontal problems. Suggestions
must be supported with evidence and rationale. Indicate recommendations for:
a. Home care
b. Additional treatment to be rendered by a dentist
c. Indicate referrals
d. Recall appointments
Prognosis
Make a forecast on the potential patients’ success in controlling his or her periodontal condition using
variables such as general health, degree of bone destruction, tissue resolution, motivation and home care.
A treatment plan for maintenance should be included stating the appropriate rationale where applicable.
Use terms such as: excellent, good, fair and poor.
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229
Periodontal Case Consultation
PCI Consultation
November 12th 2024
1:00pm
Medical History
· Patient is a 67 year old, African American woman.
· Patient has no known allergies to any drugs, food, latex or pollen
· In 2016, the patient was hospitalized for five days for fibroids surgery.
· The patient is not currently under any medical treatment for any conditions, syndromes, disorders or ailments.
· Patient is an ASA class 1
· Vital Signs were taken on October 24th 2024
· Blood Pressure: Right arm: 128/71 Left arm: 125/73
· Pulse: 68 bpm
· Temperature: 97.5
· Respiration: 18bpm
Dental History
· Patient has had a few teeth extracted over the years. The patient does not have any discomfort in her mouth. Patient Maryland bridge that she had placed at 21 years old came off on 10/17/14. On 11/6/24 the patient went to the doctors to get a temporary crown placed on tooth #2.
· Last dental radiographs taken were a FMS on 10/24//2024 along with vertical bitewings on 11/7/2024 and intraoral photos.
· Pt is missing tooth #’s 1,7,8,14,16,18, and 30. None have been replaced
Oral Inspection
· TMJ: grinding when opening and closing bilaterally, Patient stated that there is pain occasionally on the left side when opening and closing but not currently experiencing pain or tenderness
· Lymph nodes: bean shaped, freely moveable, no pain or tenderness
· Thyroid: freely moveable when swallowing
· Skin and lips: Smooth, intact, even in color, unilaterally right side vermillion zone is sunk in because of missing #7 and #8 (facial collapse).
· Oral mucosa: Linea alba bilaterally, pink and keratinized, less than 1mm lesion on unilaterally right side that is red in color, buccal mucosa has a swollen (gummy appearance)
· Tongue: Dorsal surface slightly coated white, lateral border is scalloped, patient presents with a tongue thrust
· Floor of mouth: Sublingual frenulum present, adequate salivary flow, no lesions, mandibular torus present highly prominent on unilaterally right side , adequate lingual frenum attachment coral pink
· Hard palate: Smooth, pink, firmly attached to bone, high vault, very slight petechiae present
· Soft palate: no lesions, smooth, pink in color
· Maxillary tuberosity: firm, pink in color
· Tonsils: Present, Unilaterally right side is slightly red and enlarged red
· Retromolar areas: spongy, keratinized, white/purple in color unilaterally left side, 3rd molars are present
· Occlusion: Bilaterally Class 1(canine relationship)
· Overjet: 3mm
· Overbite: Slight- incisal one third
· Midline: Deviated to the right 3mm
Gingival Description
Gingival Condition
Papillary
Marginal
Attached
Color
Generalized: Pigmented
Localized:
White between #9/10- lingual surface
Generalized:Pink
Localized:
#31 keratinized,#10,#11(lingual surfaces) pale pink
#31,#32(lingual) pigmented
Generalized: Pigmented
Localized:
Lingual #14 keratinized, #30 pigmented
Contour
Generalized: Pyramidal
Localized:
#12,#13, #11,#31 blunted
Generalized:Rolled(rounded)
Generalized:Adequate Width
Localized: inadequate width #3,29,19,20,15,9
Consistency
Generalized:Spongy
Localized:#7,8 fibrotic
Generalized:Spongy
Localized: n/a
Generalized:Bound firmly to underlying bone
Localized:n/a
Texture
Generalized:Spongy/Stippled
Localized: n/a
Generalized:Smooth
Localized: n/a
Generalized:Stippled
Localized: #7,8,9 fibrotic
Size
Generalized: slightly enlarged
Localized: #9,10,31, enlarged
Generalized:slightly enlarged
Localized:#31 enlarged
Generalized:enlarged
Localized:#3-5,12,13L not enlarged
Position
Generalized: Fills interproximal space
Localized: #23-25 does not fill interproximal space
Generalized:Leveled with CEG
Localized:#13,29,19,3 below the CEJ.
Generalized: Adequate width
Hard Tissue Charting: 25 Clinical Crowns
Abrasion
None
Attrition
22,23,24,25,26
Erosion
None
Exudate
None
BOP
#3,4,5,6,11,17,19,26,27,31
Furcation
None
Incipient Caries
#2,13,,19,20,
Mobility
#24,25,26 1mm
Versions
13m, 18d, 22d, 23d, 24m
Widening of the PDL-
Thickening of the Lamina Dura-
Gingival Index
Tooth #
Mesial
Facial
Distal
Lingual
3
2
2
2
1
9
2
2
2
1
12
2
2
2
2
19
2
1
1
2
25
1
0
0
1
28
2
2
2
1
TOTAL=
11
9
9
8
Combined Total:
37
37/24=1.54 GI (Moderate Inflammation)
total/# of surfaces=gingival index
Exudate- patient presents with no exudate
Mobility- Tooth number #26,25,24 1mm involvement
Pocket Formation- Patient presents with pockets greater than 4mm on 22 surfaces
Radiographic Findings
Tooth #
Horizontal
Vertical
Tooth #
Horizontal
Vertical
1
missing
missing
9
DM
2
DM
10
MD
3
DM
11
MD
4
DM
12
M
5
M
M
13
DM
6
14
7
missing
missing
15
D
M
8
missing
missing
16
missing
missing
Tooth #
Horizontal
Vertical
Tooth #
Horizontal
Vertical
25
MD
17
M(slight)
26
18
missing
missing
27
M
19
M
D(slight)
28
M
20
MD
29
MD
21
MD
30
missing
missing
22
D
M
31
MD
23
MD
32
MD
24
MD
Treatment Plan
Treatment 1: Patient came in on 10/24/2024. Medical and dental history was documented. Recorded all vital signs. Blood pressure was as follows: right arm :128/71, left arm:125/73, pulse- 68 bpm, respiration 18, temp-97.5. The patient had no significant medical concerns but she stated that she underwent surgery for fibroids in June of 2016 and was hospitalized for five days. The patient stated she recently went to the dentist 1 month ago because her Maryland bridge had fallen out. Pt has a history of asthma at the age of 6 years old but it has been dormant for over a century. Patient is an ASA classification 1. The patient’s last dental radiographs were from May 27 2022, the patient was due for an updated radiographic evaluation. Exposed a Digital Full Mouth Series using 18 films. As I was exposing the patient I noticed radiographic bone loss and explained it to her.
Treatment 2: Reviewed medical and dental history. The patient stated that she had a temporary crown placed on tooth #2 and that she was going to her general dentist to get the permanent crown placed within a week. I briefly discussed the maintenance and home care of the temporary crown with the patient as she seemed very compliant. Evaluated patients vital signs. Respiration- 18, Temp-97.5. Completed oral inspection, hard and soft tissue charting (periodontal probing) where I found generalized pocketing, bleeding on probing, slight mobility, and bone loss. Requested to expose the patient to 4 vertical bitewings in order to assess bone levels and detect interproximal decay. Schedules patient for her follow up appointment. Patient was dismissed
Treatment 3: Reviewed medical and dental history, there were no changes. Evaluated patients vital signs respiration was 16 bpm, temp-97.7. Revaluated all findings and filled in the PCI approval form and presented PCI. Patient was approved to proceed with intraoral photos. Pt OHC was taken and determined she was a class III. Scheduled patient for follow up appointment. Patient was dismissed.
Treatment 4: Reviewed medical dental history patient presented with no changes.Patients maxillary arch and mandibular arch impressions were taken but there was no gypsum yellowstone in the clinic. Patient impressions were taken with alginot and wrapped to be poured for evaluation when stone is available. Discussed the importance of homecare and went over patient education. Scheduled periodontal consultation with the dentist and patient dismissal.
Treatment 5:
Medical and dental history review. Reevaluate patients progress from recommendations during patient education and reiterate how to improve. Take the patient’s blood pressure and document it in clinical notes. Apply Benzocaine 20% topically to dried intraoral tissues at injection sites for 1-2 minutes. Administer local anesthetics to the right side, both maxillary and mandibular. Since there are no contraindications, I will be using Lidocaine 2% 1/100,000. Complete scaling on the right side. Complete root planning on pockets 4mm or greater such as: Facial #’s 2D, 4DL, 5M, 9M,12D, 17MCD, 19CM,28M,32DM. Polish with pumice, irrigate with chlorhexidine. Schedule patient for the next appointment. Dismiss patient
Treatment 6:
Medical and dental history review. Reevaluate patients progress from recommendations during patient education and reiterate how to improve. Place arestin in 5mm or greater pockets, enforce good oral hygiene home care. Schedule patient to come back in 2-3 months, reevaluate patient checking for areas that arestin was placed and enforce home care.
Patient MRD for Local Anesthesia
Healthy patient ASA I classification, 170lbs
1.7ml Lidocaine 2% w/epinephrine 1:100,000 3.2mg/lb
2% lidocaine 2 x 10= 20 mg/ml
20 x 1.7 = 34 mg per cartridge
MRD is 300 mg per appointment
170lbs x 2 mg/lb lidocaine = 340 mg (over MRD)
340/34 = 10 Cartridges
300/34 = 8.8 Cartridges
Epinephrine
1: 100,000 epi in 2% lidocaine 1.7 solution
1000/ 100,000= 0.01 ml
1.7 ml x 0.01 =0.017 mg epi per cartridge
Healthy pt =0.2 mg
0.2 mg/ 0.017 = 11.7 cartridges
Limiting dose of of lidocaine is 8 cartridges
Prognosis
The patient is highly motivated to improve her oral health and demonstrates good homecare practices. She is actively engaged in her treatment, working collaboratively with me as a co-therapist, which supports a favorable prognosis. She has committed to regular dental visits to maintain our progress, manage her periodontal disease, and reduce her caries risk by controlling plaque levels. The referrals and oral hygiene education provided have been beneficial, and she and I are confident that, together, we can sustain her oral health.
