Patient Profile: Patient is a 38-year old White Caucasian male.
Chief Complaint: “My teeth hurt and gums bleed frequently.”
Dental History: The patient has not seen a dentist in 7 years.
Medical History: The patient has not seen a physician for over 10 years. His family history includes diabetes, cardiovascular disease, and hyperthyroidism. He reports a history of GERD and takes (Omeprazole) Prilosec® and Magnesium 400 mg daily. Vital signs recorded: Blood Pressure (RAS): 138/98; Pulse: 110 BPM; Respiration: 20 Breaths/Minute
Assessment reported within normal limits.
Patient presented with moderate to heavy calculus.
Generalized moderate to heavy bleeding upon probing with localized heavy bleeding in the mandibular anterior sextant, and localized heavy bleeding in the mandibular right and left posterior molars.
Lack of interest demonstrated.
Patient brushes with a hard bristled manual toothbrush only if he remembers.
Patient does not floss.
Patient uses a phenol mouthrinse several times daily.
Consumes soft drinks and high energy drinks several times daily.
Bleeding Index: 75%
Plaque Free Score: 35%
Social History: He reports no history smoking cigars or cigarettes.
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