Case Study 15

Patient Profile: Patient is a 65-year old White Caucasian male retired bus driver.

Chief Complaint: "I have trouble tasting my food, so I only like to eat spicy foods."

Dental History: The patient had periodontal therapy consisting of periodic scaling and root planning. It has been three years since his last dental visit.

Medical History: The patient reports having a stroke eight years ago and now suffers with slurred speech and a reduction in salivary flow. He currently takes (Enalapril) Vasotec® and his blood pressure was recorded at 130/80.

Extraoral Examination:

  • Assessment reported all within normal limits.

Supplemental Information:

  • Patient demonstrates a rapid scrubbing motion.
  • He has used a phenol mouthrinse for years and reports a burning sensation on his tongue.

Health Behaviors:

  • Patient brushes twice daily.
  • Patient does not floss regularly.

Bleeding Index: 43%

Plaque Free Score: 35%

Social History: Likes to fish and drinks alcohol occasionally.

PERIODONTAL CHARTING

Case 15

STUDY MODEL

Mandibular Anterior Lingual/Maxillary Palatal Mandibular Anterior Lingual/Maxillary Palatal
Full Direct Full Direct
Right Side Right Side
Left Side Left Side

RADIOGRAPHIC IMAGES

Click to view a larger image:
R
Left1
Left2
Left3
Upper
Upper
Right1
Right2
Right3
L

Intraoral Images

Left Side Left Side
Right Side Right Side
Maxillary Anterior Palatal Maxillary Anterior Palatal
Mandibular Anterior Lingual Mandibular Anterior Lingual
Left Palatal Left Palata
Right Palatal Right Palatal
Left Lingual Left Lingual
Full Direct Full Direct

QUESTIONS

Your Faculty has access to the answers in this case study. Please ask them to look in the Faculty Corner for the answers to this case.
  1. Using Angle's classification of malocclusion, the patient's occlusal status can BEST be described as:
  1. Teeth #18-20 represent 5-6 mm pocket readings. What statement BEST describes how this finding was determined?
  1. Based on the client's chief complaint, the dental hygienist should recommend all the following except. What is the EXCEPTION?
  1. The dental hygiene care plan for this patient should include all the following except. What is the EXCEPTION?
  1. According to G.V. Black's classification of restorations, the following BEST describes tooth #18:
  1. The posterior bitewing radiographs demonstrate an iatrogenic error described as:
  1. The anatomical landmarks observed in the maxillary anterior sextant periapical radiographs include all of the following EXCEPT:
  1. The ASA physical status classification for this client is:
  1. To initiate the BEST course of periodontal therapy, the clinician should:
  1. The mandibular right posterior periapical radiographs exhibit overlapping of tooth structures as a result from: