Patient Profile: Patient is a 48-year old White Caucasian male, 5’9” and weighs 175 lbs. He is employed at an industrial warehouse.
Chief Complaint: “Tartar builds up on my bridge and my gums bleed when I brush. You will have a difficult time cleaning my teeth.”
Dental History: Patient was diagnosed with periodontal disease and teeth #23-26 were extracted and replaced with a fixed bridge several years ago. He does not follow recommended recare appointment intervals.
Medical History: The patient has recently been under the care of a physician for a right shoulder injury. He was diagnosed with Hepatitis A over 30 years ago. He has an occasional outbreak of genital herpes. His current medications include: (Enalapril maleate) Vasotec®, (Valsartan) Diovan®, (Paroxetine hydrochloride) Paxil®, (Lorazepam) Ativan®, (Valacyclovir hydrochloride) Valtrex®, 81 mg daily aspirin and (Naproxen) Aleve® as needed. His blood pressure was recorded at 155/98.
Bleeding Index: 45%
Plaque Free Score: 30%
Social History: He smoked for 15 years and quit about 5 years ago.