Patient Profile: Patient is 23-year old White Caucasian male.
Chief Complaint: "I need my front teeth to look good for my wedding pictures."
Dental History: The patient has not seen a dentist for over 10 years.
Medical History: The patient has not seen a physician for many years and appeared agitated when the recommendation was suggested. His family history includes hypertension, alcoholism and substance abuse. He reports a history of cigar and cigarette smoking, frequent stomach indigestion and remarked he is in good health. He currently takes (Lansoprazole) Prevacid® and (Ibuprofen) Advil® as needed. Vital signs recorded – Blood Pressure: 142/98; Pulse: 110 BPM; Respiration: 25 Breaths/Minute.
Assessment reported within normal limits.
Patient presented with moderate calculus and heavy plaque.
Generalized moderate bleeding upon probing with localized heavy bleeding in the maxillary anterior sextant, papillary erythema and edema in the maxillary left posterior region.
Smokes 1-3 cigars weekly and 1 pack of cigarettes daily.
Lack of interest and motivation to seek additional care.
Patient brushes with a hard bristled toothbrush once daily if he remembers.
Patient does not floss.
Patient uses a phenol mouthrinse several times daily.
Drinks cola, high energy drinks and orange juice several times throughout the day.
Bleeding Index: 65%
Plaque Free Score: 30%
Social History: The patient is planning to marry in 3 weeks. He has been smoking cigars for 2 years and has smoked cigarettes for 9 years.
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