Case Study 31

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

Extraoral Examination:

  • Assessment reported within normal limits.

Supplemental Information:

  • 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.

Health Behaviors:

  • 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.


Case 31 - Periodontal Chart


Click to view a larger image:
Case 31 - radiographs

Right Side Case 31 -right
Left Side Case 31 - left
Full Direct Case 31 - full direct
Mandibular Facial Case 31 - mandibular facial
Maxillary Palatal Case 31 - maxillary palatal


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. Which of the following teeth MOST likely have a poor prognosis?
  1. According to Angle’s Classification of malocclusion, what relationship is demonstrated on the patient’s left side?
  1. What common characteristic is observed in #’s 3, 5, 6, 12, 13?
  1. What lesions are MOST likely present on the labial mucosa?
  1. According to G.V. Black’s classification of restorations, the classification for tooth #14 is:
  1. What phase of therapy will BEST address this patient’s dental care planning?
  1. According to the AAP Classification, what BEST describes the patient’s periodontal status?
  1.  Burnished calculus is present on the mesial and distal surfaces on the posterior teeth.  Which instrument should initially be used and then followed with additional periodontal instruments?
  1. Local anesthesia was administered and proven ineffective while debriding #24, #27, #28. What BEST explains this occurrence?
  1. What is MOST likely the oval radiolucency between the maxillary central incisors on the panoramic radiograph?