Patient Profile: Patient is a 41-year old White Caucasian female, 5’6” and weighs 165 lbs.
Chief Complaint: "My front teeth are sensitive to cold."
Dental History: Patient saw a dental hygienist four years ago and followed recommended recare intervals for six months and has not received any professional dental care since.
Medical History: Patient had a hysterectomy nineteen years ago and bladder surgery nine years ago. She has a family history of type 2 diabetes. She remarked about being frequently thirsty and that "sugar makes her sick." Patient reports a history of hepatitis and was unsure of the type. Medications include: (Escitalopram oxalate) Lexapro®, (Enalapril maleate) Vasotec® and a daily 81 mg aspirin. Her blood pressure was recorded at 145/92.
Assessment reported within all normal limits.
Patient presented with moderate calculus and heavy plaque.
Patient does not floss.
She uses a manual medium bristled toothbrush once daily.
Reports using a daily phenol rinse to remove a bad taste.
Bleeding Index: 45%
Plaque Free Score: 30%
Social History: She smokes 1½ packs of cigarettes daily and has been smoking for 20 years.
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